labeled_data
,text,label
0,"admission date: [**2120-9-20**] discharge date: [**2120-9-30**] date of birth: [**2075-5-1**] sex: f service: medicine allergies: no known allergies / adverse drug reactions attending:[**first name3 (lf) 3958**] chief complaint: presyncope major surgical or invasive procedure: pericardial window history of present illness: this is a 45 y/o female with past medical history of hypothyroidism presenting initially for an urgent care visit with an episode of diaphoresis and presyncope several hours prior. the patient has had ~1 month of bilateral neck discomfort associated with mild dyspnea on exertion. her neck pain improved with physical therapy and her neck pain improved. she now reports worsening doe and worsening neck pain over the past 1 1/2 weeks. she now has difficulty walking up a single flight of stairs. additionally, she reports that for the past few days, she hasn't been ""feeling herself"", with fatigue, nausea, vomitting, decreased po. on day of presentation she was leaving work, walking to car when had acute onset of diaphoresis and presycnope associated with sob; no fall /headstrike. no palpitations. presented to clinic for further evaluation. in clinic triage noted to be tachycardic to 116. on review of systems she reports low grade fevers (but has been taken ibuprofen regularly), 5 pounds of weight loss over past 2 weeks, day&nightime sweats (and felling 'hot'), with increasing nausea/vomitting. she has had no lymphadenopathy, abdominal pain, change in her bowel or bladder habits, muscle or joint pain. of note, on review of history had recent tsh of .088 [**7-26**], for which she had levoxyl dose decreased and cytomel dose kept the same. in the ed, initial vitals were 100.0 116 126/88 18 99% labs and imaging significant for new anterior mediastinal mass. she had elevated wbc to 14.1 with 89.7%neutrophils, hb:10.4 plt:468. chem 7 wnl. tsh, ft4 pending. d-dimer 5515, but cta negative for pe. patient given zofran. on arrival to the floor, patient complained of pleuritic chest pain and intermittent nausea past medical history: hypothyroidism/hashimoto's disease dyspepsia hepatitis irritable bowel syndrome s/p fibroadenoma excision, right breast varicose veins, s/p sclerotherapy allergic rhinitis tonsillectomy/adenoidectomy social history: levothyroxine [levoxyl] 88mcg daily liothyronine [cytomel] 10 mcg qam, 2.5 mcg qpm calcium and vitamin d two tablets in the evening, vitamin d [**2108**] units a day, magnesium oxide 400 mg a day, metamucil, selenium 100 mcg a day, vitamin b complex with biotin. family history: father living, age 73, hypertension, positive for h. pylori on endoscopy, history of colon cancer, prediabetes. mother living, age 66, high cholesterol. two brothers, one with hypertension and ulcers. one brother and sister who are healthy. daughter is 19 years old, graduated from high school and going to [**university/college 3959**]in the fall, going to live at home. son [**name (ni) **] 17 years old, going into his senior year of high school. family history positive for breast cancer in two maternal aunts. family history negative for coronary artery disease, mi, cva, and diabetes mellitus. physical exam: admission exam: vs: t=98.4 bp=109/77 hr=120 rr=19 o2 sat= 97%ra general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. neck: supple with jvp of 10 cm. cardiac: tachycardic, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were somewhat labored intermittently, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ discharge exam: general - well-appearing woman in nad, comfortable, appropriate heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear neck - supple lungs - clear to ausculation bilaterally heart - pmi non-displaced, rrr, no mrg, nl s1-s2 abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - wwp, 2+ peripheral pulses (radials, dps); 1+ trace edema bilaterally skin - no rashes or lesions lymph - no cervical, axillary, or inguinal lad neuro - awake, a&ox3, pertinent results: admission labs: [**2120-9-19**] 06:18pm wbc-14.1*# rbc-3.73* hgb-10.4* hct-32.6* mcv-87 mch-27.8 mchc-31.8 rdw-13.9 [**2120-9-19**] 06:18pm neuts-89.7* lymphs-5.0* monos-5.0 eos-0.2 basos-0.2 [**2120-9-19**] 06:18pm plt count-468*# [**2120-9-19**] 06:18pm hcg-<5 [**2120-9-19**] 06:18pm tsh-0.67 [**2120-9-19**] 08:14pm d-dimer-5515* [**2120-9-19**] 06:18pm glucose-125* urea n-16 creat-0.5 sodium-138 potassium-4.7 chloride-101 total co2-26 anion gap-16 [**2120-9-20**] 09:13am cea-<1.0 [**2120-9-20**] 04:28am alt(sgpt)-41* ast(sgot)-19 ld(ldh)-485* alk phos-220* tot bili-0.6 [**2120-9-20**] 09:21am blood type-art po2-87 pco2-25* ph-7.43 caltco2-17* base xs--5 discharge lab [**2120-9-30**] 06:15am blood wbc-21.4* rbc-3.82* hgb-10.7* hct-31.9* mcv-84 mch-28.0 mchc-33.5 rdw-13.5 plt ct-333 [**2120-9-30**] 06:15am blood neuts-95.2* lymphs-2.7* monos-0.4* eos-1.7 baso-0 [**2120-9-30**] 06:15am blood glucose-116* urean-8 creat-0.5 na-137 k-4.1 cl-102 hco3-28 angap-11 [**2120-9-30**] 06:15am blood alt-30 ast-20 ld(ldh)-249 alkphos-135* totbili-1.0 [**2120-9-30**] 06:15am blood calcium-8.8 phos-2.8 mg-2.1 uricacd-3.1 micro urine culture (final [**2120-9-27**]): culture workup discontinued. further incubation showed contamination with mixed skin/genital flora. clinical significance of isolate(s) uncertain. interpret with caution. proteus mirabilis. 10,000-100,000 organisms/ml.. presumptive identification. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ proteus mirabilis | ampicillin------------ <=2 s ampicillin/sulbactam-- <=2 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s pathology [**9-20**] pericardium, mediastinal mass biopsy specimen #1: pericardium, biopsy (a). diagnosis: cardiac muscle and fibroadipose tissue with fibrin deposition and granulation tissue reaction. there is no morphologic evidence of involvement by lymphoma. specimen #2: soft tissue mass, right anterior mediastinum, biopsy (b-c). diagnosis: diffuse large b-cell lymphoma, primary mediastinal (thymic) type, see note. specimen #3: soft tissue mass, right anterior mediastinum, biopsy (d-e). diagnosis: diffuse large b-cell lymphoma, primary mediastinal (thymic) type, see note. note: h&e sections (b through e) reveal fibrous tissue with abundant geographic necrosis and infiltration by an atypical lymphoid population in an invasive and reticulated growth pattern with delicate interstitial fibrosis. the tumor cells are large with moderately abundant amphophilic cytoplasm. the nuclei have pale chromatin, irregular and angulated nuclear contours, and small inconspicuous nucleoli. scattered mitoses and apoptotic bodies are seen. by immunohistochemistry, tumor cells are pan reactive with cd45 and in addition, immunoreactive for cd20 and pax-5, with co-expression of cd30, mum1, and bcl-6. the admixed reactive t-cells are positive for cd3 and cd5. the tumor is negative for cd10, cd15, and cd56, which shows only rare scattered positive cells. the tumor cells are negative for cytokeratin cocktail (which stains the fibroblasts), synaptophysin, s-100, and tdt. the proliferation index, by mib-1 staining, is approximately 80-90%. the combined clinical, morphologic, and immunophenotypic findings are most consistent with the diagnosis of primary mediastinal large b-cell lymphoma. [**2120-9-23**] flow cytometry report flow cytometry immunophenotyping the following tests (antibodies) were performed: hla-dr, fmc-7, kappa, lambda, and cd antigens 3,5,10,19.20,23,45. results: three color gating is performed (light scatter vs. cd45) to optimize lymphocyte yield. b cells comprise 1% of lymphoid-gated events, (<1% of total events), and do not express aberrant antigens. t cells comprise 63% of lymphoid gated events, 3% of total events, and express mature lineage antigens. interpretation nonspecific t cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by lymphoma are not seen in specimen. correlation with clinical findings and morphology (see s12-40728k) is recommended. flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. [**2120-9-23**] bone marrow biopsy diagnosis: hypercellular bone marrow with maturing trilineage hematopoiesis. there is no morphologic evidence of involvement by lymphoma. microscopic description peripheral blood smear: the smear is adequate for evaluation. erythrocytes are decreased, with mild anisopoikilocytosis including occasional echinocytes, and rare target cells. the white blood cell count is normal. occasional hypersegmented neutrophils are seen. the platelet count appears normal. occasional large platelets are seen. a manual differential shows: 97% neutrophils, 0% bands, 3% lymphocytes, 0% monocytes, 0% lymphocytes, 0% eosinophils, 0% basophils. aspirate smear: the aspirate material is adequate for evaluation. m:e ratio is 1.5:1. erythroid precursors are relatively proportionately decreased in number and exhibit overall normoblastic maturation with rare cells with irregular contours. myeloid precursors are relatively proportionately increased in number and show normal maturation. megakaryocytes are increased number. abnormal forms are not seen. a 500 cell manual differential shows: 0% blasts, 4% promyelocytes, 7% myelocytes, 8% metamyelocytes, 38% bands/neutrophils, 37% erythroids, 6% lymphocytes, 0% plasma cells. biopsy slides: the core biopsy material is adequate for evaluation. it consists of a 1.1 cm core biopsy of trabecular marrow with a cellularity of 70%. m:e ratio estimate is increased. the bone appears mildly osteopenic. erythroid precursors are relatively proportionately decreased in number in number and have overall normoblastic maturation. myeloid precursors are relatively proportionately increased in number with normal maturation. megakaryocytes are increased in number, with focal loose and tight clustering. imaging 2-d echocardiogram [**2120-9-19**]: the estimated right atrial pressure is at least 15 mmhg. left ventricular wall thicknesses are normal. 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 65%). the right ventricular free wall is thick. there is a 1 cm thick soft tissue rind abutting the right ventricular free wall, largest at the atrioventricular groove. this could represent an acoustically dense epicardial fat pad or an extensive epicardial tumor/metastasis. right ventricular free wall infiltration cannot be excluded, especially in light of the thickened, hypocontractile appearance. right ventricular chamber size is normal with depressed free wall contractility. the aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. the mitral valve leaflets are structurally normal. the pulmonary artery systolic pressure could not be determined. there is a large pericardial effusion. the effusion is echo dense, consistent with blood, inflammation or other cellular elements. stranding is visualized within the pericardial space c/w organization. there is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. consider cardiac mri to better assess the possibility of right ventricular free wall infiltration read by: [**first name8 (namepattern2) **] [**name8 (md) **], md echocardiogram post-pericardial window: [**2120-9-21**] impression: normal biventricular systolic function. abnormal septal motion, likely due to effusive-constrictive physiology (commonly seen for a limited time after pericadiocentesis). mediastinal mass abutting the right ventricular free wall. compared with the prior study (images reviewed) of [**2120-9-19**], the previously seen pericardial fluid is no longer present. both ventricles appear larger as a result. no evidence of tamponade physiology. read by: [**first name4 (namepattern1) **] [**last name (namepattern1) **] echocardiogram [**2120-9-23**] left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the mitral valve appears structurally normal with trivial mitral regurgitation. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. there is an anterior space which most likely represents a prominent fat pad. there are no echocardiographic signs of tamponade. there is a mediastinal mass compressing the heart. impression: no evidence of significant pericardial fluid or tamponade physiology. mediastinal mass anterior to the right ventricle. compared with the prior study (images reviewed) of [**2120-9-21**], the septal bounce has resolved. other findings are similar. [**2120-9-30**] echo 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. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is a trivial/physiologic pericardial effusion. there is an anterior space which most likely represents a prominent fat pad. there are no echocardiographic signs of tamponade. brief hospital course: this is a 45 year f with past medical history of hypothyroidisim presenting with diaphoresis, presyncope, and severe doe and found to have an anterior medialstinal mass consistnet with primary mediastinal large b- cell lymphoma on pathology, transfered from ccu after pericardial window and resolution of tamponade to bmt service for intiation of r-[**hospital1 **] #primary mediastinal large b-cell lymphoma- the patient presneted with dyspnea and pleuritic chest pain. a ct chest done as part of her evaluation was notable for a anterior mediastinal mass. biopsy of the pericardium and mediastinal mass was positve for b-cell lymphoma. r-[**hospital1 **] chemotherapy was intiated for treatement, and a bone marrow biospy was done. the patient experienced an adverse reaction during infusion of rituxan ( see below), but tolerated the remainder of her treatment course without complication. she will follow up with her primary oncologist dr. [**last name (stitle) **] for further mangement. # afib w/ rvr- the patient triggered twice during infusion of rituxan on day 1 of r-chop. during the infusion of rituxan on day 1 of r-chopthe patiet became hyptoensive to 80s/50s, with associated palpitations, but arousable when the rate of rituxan was increased from 50 to 100 mg/hr. the patient was found to be in afib with rvr ( hrs 130s-150s) on telemetry ( confirmed by ekg). rituxan was stopped, iv hydrocortisone 100mg x2 was and 1 l ivfs were given. the patient convereted to nsr hr in he 80s with out any intevention, and resolution of palpitation. the bmt atending was notified and the decision wasmade to restart rituxan at 0mg/hr,and if an further complications would stop completely. two hours after inital episode the patient was satiing 91 on 2l, was normotensive with hr 80. rituxan was stopped pending repeat echo, as asses cardiac function. 3 hours after discontinuing rituxan the patient returned to afib with rvt, hr 130s, although the patient was asymptomatic at this time. she received iv metoprol mg x 2, and started on metoprolol 12.mg po id. she converted back to nsr 1 hour later. an echo was done the next morning, significant for an lvef > 55%. her afib was most likley a exaggerated inflammatory reaction to rituxan. she was evaluated by cardiology who did not recommend long term anticogualtion for her afib, and to rate control with nodal agents if recurred. ?she had no further episodes during her hospital course # pulmonary embolism- the patient was found to have a right subsegmental pe and on cta. she was treated with a heparin gtt and transitioned to lovenox on discharge. duration of therapy to be determined by primary oncologist. # pericardial effusion/tamponade- the patient most likely had a malignant effusion secondary to her primary mediastinal large b-cell lymphoma. went for pericardial window [**9-20**], drained 250cc fluid. gram stain of fluid and tissue negative for organisms, 2+ polys and 0 polys, respectively. pericardial drain was pulled on [**9-21**] and f/u echo showed resolution of pericardial effusion. she was monitored with serial echos during her hospital course which did not show reaccumulation of the pericardial effusion. # urinary tract infection- the patient noted to have hematuria. a ua and urine cx were sent which grew proteus. she was treated with a 7 day course of ciprofloxacin. ---------- chronic stable issues # hypothyroidism- the patient was continued on home medications levoxyl, cytomel . medications on admission: preadmission medications listed are correct and complete. information was obtained from patient. 1. levothyroxine sodium 88 mcg po daily 2. liothyronine sodium 15 mcg po daily 3. calcium carbonate 500 mg po frequency is unknown 4. vitamin d 400 unit po frequency is unknown 5. magnesium oxide 400 mg po daily 6. psyllium 1 pkt po frequency is unknown 7. selenium sulfide dose is unknown tp frequency is unknown 8. vitamin b complex 1 cap po daily discharge medications: 1. levothyroxine sodium 88 mcg po daily 2. liothyronine sodium 10 mcg po qam 3. liothyronine sodium 2.5 mcg po qpm 4. vitamin d 400 unit po bid 5. enoxaparin sodium 80 mg sc q12h rx *enoxaparin 80 mg/0.8 ml administer 1 injection subcutaneously twice a day disp #*60 syringe refills:*1 6. calcium carbonate 500 mg po frequency is unknown 7. ciprofloxacin hcl 500 mg po q12h duration: 7 days rx *ciprofloxacin 250 mg 1 tablet(s) by mouth twice a day disp #*6 tablet refills:*0 8. filgrastim 480 mcg sc q24h duration: 10 days 9. prochlorperazine 10 mg po q6h:prn nausea rx *prochlorperazine maleate 10 mg 1 tablet(s) by mouth 6 hours disp #*60 tablet refills:*0 10. scopolamine patch 1 ptch tp once duration: 1 doses 1 patch q 72 hours. should be removed on [**10-2**] discharge disposition: home discharge diagnosis: primary diagnosis primary mediastinal large b cell lymphoma pulmonary embolism/deep venous thromboembolism secondary diagnosis hypothyroidism discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. [**known lastname 3960**], it was a pleasure participating in your care at [**hospital1 18**]. you were admitted to the hospital because you were feeling short of breath, lightheaded, with associated sweating. you were found to have a cancer in your chest ( primary mediastinal large b cell lymphoma) and a blood clot in your lungs ( pulmonary embolism). you were also found to have a clot at the site of your picc line, and the line was ultimately removed. you were started on blood thiners to treat your blood clot ( lovenox also known as enoxaparin) which you will continue to take on discharge. for you cancer you finished your first cycle of chemotherapy and will follow up with your primary oncolgoist dr. [**last name (stitle) **] at the appointments scheduled for you below. your neupogen was discontinued prior to discharge, because your white count was elevated. please discuss with dr. [**last name (stitle) **] when to resume these injections at your next visit followup instructions: department: hematology/oncology when: wednesday [**2120-10-2**] at 12:45 pm with: checkin hem onc cc7 [**telephone/fax (1) 22**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) **] campus: east best parking: [**hospital ward name 23**] garage department: hematology/oncology when: wednesday [**2120-10-2**] at 1:30 pm with: [**first name8 (namepattern2) **] [**name8 (md) **], md [**telephone/fax (1) 3961**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) **] campus: east best parking: [**hospital ward name 23**] garage [**first name8 (namepattern2) **] [**name8 (md) **] md [**md number(2) 3962**]",1
1,"admission date: [**2200-6-1**] discharge date: [**2200-6-3**] date of birth: [**2122-3-19**] sex: f service: medicine allergies: no known allergies / adverse drug reactions attending:[**doctor first name 3290**] chief complaint: body pain major surgical or invasive procedure: none history of present illness: 78y/o f h/o diabetes, chronic back pain, recurrent sbo requiring multiple surgeries who presents to the ed with hypotension after reported fall. admitted to icu for monitoring of hypotension. pt was seen recently in the ed [**5-30**] for left wrist pain and itching after splinted [**5-27**] from fall-related ulnar and distal radius fractures. she had been feeling alright at home but today felt fatigue, nausea, diffuse body aches and joint aches, with subjective fevers at home. she had some mild headache but no altered mental status/confusion or neck stiffness to suggest meningitis. patient may have had another fall last night. . ed course: v/s: 97.6 109 127/74 20 95% on 2l nc. developed fever to 102 (oral). pt was noted to have a nonproductive cough. interventions: pt was given morphine at 10:30 am for total body aches. also given ctx, azithro, nebs for possible pna and 2l ivf. pt then triggered for hypotension to 85 systolic from previous pressures in 150s, moved from the periphery to the core and given an additional 2l ivf ns along with vancomycin. pt received 125mg methylpred for wheezing. flu swab sent. after total 4l sbp in low-mid 90s. . on arrival to the icu, pt noted to be extremely somnolent which had not been noted before. could barely whisper her first name and only opened her eyes for several seconds in response to sternal rub and voice commands. pt received 0.4mg narcan and immediately became more alert, crying out that she was cold and that her back was cold. denied pain. would not answer any history questions other than , did not know the year. did know that she was in the hospital and that it was [**hospital3 **]. pt was also administered another liter of ns. . spoke with pts son who states that she has become increasingly depressed although fully functional still at home. in the last year bought a cemetery plot and whenever something happens to her for example her recent wrist fracture she goes and visits the plot. . review of systems: unable to obtain fully, pt altered. son saw her day before yesterday and denies that she complained of the following or that he noted any of the following. (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: pmhx: dm, obesity, htn, asthma, oa, jejunal divertic, peritonitis, perforated viscus, chronic back pain, plantar fasciitis . pshx: ex-lap/loa, trigger finger, sbr, jujunal diverticulotomy, tah/bso, tubal ligation he surgical history began with a perforated jejunal diverticulim in [**2191**]. since that time she has required multiple exlaps, loa for sbos. social history: - tobacco: remote - alcohol: remote - illicits: none family history: non-contributory. physical exam: admission exam: vitals: t: 98.5 (tylenol in ed) bp:103/52 p:83 r:21 o2: 99%ra general: lethargic but arousable (for brief intervals) not responding verbally appropriately, does not follow commands or answer questions although oriented to her own name. heent: sclera anicteric, mmm, oropharynx clear but dry mucous membranes neck: supple, jvp not elevated, no lad lungs: diffuse rhonchorous breath sounds cv: tachycardic, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley present ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: admission labs: [**2200-6-1**] 10:25am blood wbc-12.1* rbc-3.84* hgb-11.7* hct-36.2 mcv-94 mch-30.3 mchc-32.2 rdw-12.9 plt ct-300 [**2200-6-1**] 10:25am blood neuts-83.8* lymphs-6.9* monos-5.3 eos-3.6 baso-0.4 [**2200-6-1**] 11:52am blood pt-11.8 ptt-28.8 inr(pt)-1.1 [**2200-6-1**] 10:25am blood glucose-188* urean-12 creat-0.7 na-132* k-4.3 cl-97 hco3-24 angap-15 [**2200-6-1**] 10:25am blood alt-32 ast-43* alkphos-74 totbili-0.3 [**2200-6-1**] 10:25am blood lipase-25 [**2200-6-1**] 10:25am blood probnp-136 [**2200-6-1**] 10:25am blood ctropnt-<0.01 [**2200-6-1**] 10:25am blood albumin-3.9 [**2200-6-1**] 06:35pm blood tsh-0.37 [**2200-6-1**] 10:25am blood asa-neg acetmnp-neg bnzodzp-pos barbitr-neg tricycl-neg [**2200-6-1**] 05:47pm blood type-art po2-109* pco2-35 ph-7.39 caltco2-22 base xs--2 [**2200-6-1**] 10:28am blood lactate-1.3 [**2200-6-1**] 01:37pm blood lactate-0.9 [**2200-6-1**] 05:47pm blood lactate-0.8 na-137 k-3.7 cl-108 [**2200-6-1**] 05:47pm blood freeca-1.10* brief hospital course: 78 y/o f h/o dm, multiple abdominal surgeries for sbos, oa, falls, presents with hypotension and fever, admitted to the [**hospital unit name 153**] for hypotension, found to have altered mental status. #ams - on arrival to the [**hospital unit name 153**] noted to be lethargic not responding well to commands, oriented only to name. mental status improved with one dose of narcan, making medication effect likely source of ams as patient had received morphine in ed, in addition to home morphine/oxycodone. in addition, patient had received medications during her observation stay in the emergency room just a day prior to this admission. she insists that her chronic pain medications were not the cause of her change in mental status and her hypotension, but rather that the additional medications she received in the ed during her observation stay were culprit. she insisted on being very responsible regarding her medications. as medications have worn off, patient is now awake and alert. head ct negative for subdural in the setting of fall. patient was febrile in the ed, but is now hemodynamically stable without other fevers and cxr negative for pneumonia, making infection unlikely source of ams. patient remained lucid for the remainder of the admission, and was seen to be extremely anxious to go home. #hypotension: patient with hypotension to sbp 80s in the ed (baseline sbp 110-160). bp now stable in 120??????s since admission to the icu. given blood pressure normalized following clearance of opioids, likely opioid-induced. no further evidence of infection to support sepsis as etiology. troponin x 2 negative for evidence of cardiac ischemia. systolic blood pressures started to rise to 150 at the time of discharge so patient was instructed to continue all of her home antihypertensives. #h/o asthma - pt was reportedly wheezy in ed. s/p 125mg solumedrol. lungs clear for the remainder of the admission. #h/o anxiety - holding home diazepam in setting of ams, but patient was clearly anxious to be discharged from the hospital, and insisted on repeating every detail of her history. #h/o left wrist fracture - on long acting morphine and oxycodone at home. in setting of ams and lethargy/unresponsiveness, these medications were initially held. however, these are patient's long standing medications, so she will continue to use them, as they have not caused lethargy or change in mental status in the past. vitamin d level ordered and is pending at time of discharge. #chronic back pain- patient to resume home medications on discharge medications on admission: medications: per pcp [**name initial (pre) 626**] [**2200-5-16**] medications - prescription albuterol sulfate - 2.5 mg/3 ml (0.083 %) solution for nebulization - 1 vial inhaled four times a day as needed for shortness of breath albuterol sulfate - 90 mcg hfa aerosol inhaler - 2 (two) puffs(s) inhaled q 4h for one month then qid as needed for as needed for asthma - no substitution betamethasone dipropionate - 0.05 % cream - apply [**hospital1 **] twice a day as needed for itching chloroquine phosphate - 250 mg tablet - 1 tablet(s) by mouth twice a week clonidine - 0.1 mg tablet - 1 tablet(s) by mouth twice a day clotrimazole - 1 % cream - apply to feet once a day once a day as needed for fungal infection discontinue if you experience any 1s or rashes diazepam - 5 mg tablet - 1 tablet(s) by mouth qhs prn fluticasone - 50 mcg spray, suspension - 1 puff(s) each nostril twice a day for allergies/running nose fluticasone - 0.05 % cream - apply to affected area twice a day as needed for pruritis fluticasone-salmeterol [advair diskus] - 500 mcg-50 mcg/dose disk with device - 1 puff po twice a day for asthma furosemide - 20 mg tablet - 1 tablet(s) by mouth once a day for swelling and blood pressure gabapentin - 600 mg tablet - 1 tablet(s) by mouth three times a day for neuropathy glipizide - 10 mg tablet - 1 tablet(s) by mouth once a day for sugar hydroxyzine hcl - 25 mg tablet - 1 tablet(s) by mouth three times a day as needed for itching ipratropium-albuterol - 0.5 mg-2.5 mg/3 ml solution for nebulization - 1 vial inhaled three times a day lisinopril - 40 mg tablet - 1 tablet(s) by mouth once a day for blood pressure metformin - 500 mg tablet - 1 tablet(s) by mouth 2 q pm for diabetes (also called glucophage) morphine - 30 mg tablet extended release - 1 tablet(s) by mouth twice a day as needed for pain olopatadine [patanol] - 0.1 % drops - 1 drop eqch eye twice a day oxycodone - 15 mg tablet - 1 tablet(s) by mouth three times a day as needed for pain polyethylene glycol 3350 - 17 gram powder in packet - 1 packet(s) by mouth qd, as needed for hard stool pravastatin - 40 mg tablet - 1 tablet(s) by mouth at bedtime for cholesterol sertraline - 50 mg tablet - 1 tablet(s) by mouth once a day for sadness, depression also called zoloft trazodone - 50 mg tablet - 1 tablet(s) by mouth at bedtime as needed for sleep . medications - otc acetaminophen - 500 mg tablet - 1 tablet(s) by mouth three times a day as needed for pain also called tylenol aspirin - 81 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth once a day carbamide peroxide - 6.5 % drops - 3 drops(s) to right ear daily as needed to soften ear wax cholecalciferol (vitamin d3) - 1,000 unit capsule - 1 capsule(s) by mouth daily (daily) dextran 70-hypromellose - drops - 1 drop both eyes twice a day dextran 70-hypromellose [artificial tears] - drops - 1 drop ou four times a day as needed for eye irritation bedtime as needed for constipation neomycin-polymyxin-pramoxine [antibiotic + pain relief] - 0.35 %-10,000 unit-[**unit number **] mg/gram cream - apply to biopsy site tid-qid omeprazole magnesium [prilosec otc] - 20 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth once a day for acid polyvinyl alcohol - 1.4 % drops - 1 gt ou three times a day sennosides [senna] - 8.6 mg capsule - [**2-10**] capsule(s) by mouth once a day as needed for constipation - no substitution white petrolatum-mineral oil - cream - pply to feet and hands bidd as needed for dry, cracking skin discharge medications: 1. fluticasone-salmeterol 500-50 mcg/dose disk with device sig: one (1) disk with device inhalation [**hospital1 **] (2 times a day). 2. gabapentin 300 mg capsule sig: two (2) capsule po tid (3 times a day). 3. patanol 0.1 % drops sig: 1 drop ophthalmic twice a day: for both eyes. 4. clonidine 0.1 mg tablet sig: one (1) tablet po twice a day. 5. furosemide 20 mg tablet sig: one (1) tablet po once a day. 6. glipizide 10 mg tablet sig: one (1) tablet po once a day. 7. metformin 500 mg tablet sig: one (1) tablet po once a day. 8. lisinopril 40 mg tablet sig: one (1) tablet po once a day. 9. sertraline 50 mg tablet sig: one (1) tablet po once a day. 10. trazodone 50 mg tablet sig: one (1) tablet po qhs prn as needed for insomnia. 11. valium 5 mg tablet sig: one (1) tablet po once a day as needed for anxiety. 12. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation q4h (every 4 hours) as needed for dyspnea, wheezing. 13. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po three times a day as needed for itching. 14. morphine 30 mg tablet extended release sig: one (1) tablet extended release po twice a day as needed for pain. 15. oxycodone 15 mg tablet sig: one (1) tablet po three times a day as needed for pain. 16. pravastatin 40 mg tablet sig: one (1) tablet po once a day. 17. polyethylene glycol 3350 powder sig: 1 pouch miscellaneous once a day. 18. ipratropium bromide 0.02 % solution sig: one (1) inhalation three times a day. discharge disposition: home with service facility: [**location (un) 86**] vna discharge diagnosis: sedation, hypotension, from medication effect discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital with sedation and low blood pressure, and this appears to have been caused by medications that you received in the emergency room for your wrist pain. your blood pressures are now normal and you are in stable condition. you may continue to take all of your home medications. followup instructions: department: [**hospital 7975**] [**hospital **] health center when: monday [**2200-6-9**] at 10:45 am with: [**name6 (md) **] [**last name (namepattern4) 8268**], md [**telephone/fax (1) 7976**] building: [**hospital1 7977**] ([**location (un) 686**], ma) [**location (un) **] campus: off campus best parking: free parking on site *dr. [**last name (stitle) **] works with dr. [**last name (stitle) 8499**]",0
2,"admission date: [**2177-6-5**] discharge date: [**2177-6-9**] date of birth: [**2098-1-16**] sex: m service: medicine allergies: no known allergies / adverse drug reactions attending:[**first name3 (lf) 10593**] chief complaint: pain, falls, failure to thrive major surgical or invasive procedure: none history of present illness: patient is a 79 year-old russian speaking gentleman with h/o melanoma, left lung mass nos (refused biopsy) htn, copd, presenting from home with worsening pain in neck and shoulders, confusion, and falls. patient has presumed lung malignancy, which was diagnosed in [**9-/2176**], however, diagnosis has not been confirmed as patient refuses to have lung biopsy. over the past few weeks patient has had increasing neck and shoulder pain and has had his fentanyl patch dose increased. his daughter noted he was less active than he usually is at home, but today she felt his mental status was back to baseline. he fell several times yesterday. today she discussed this with his primary care physician, [**name10 (nameis) 1023**] felt he needs to be in the hospital. as per daughter patient had no fever, chest pain, shortness of breath, abdominal pain, nausea, vomiting. she thinks patient has had recent weight loss vitals in the er: 97.2 76 128/60 16 99% ra. he had ct head and c-spine showing no acute fracture. he had a cxr showing known cavitary lung lesion. he was given morphine 2.5mg iv with improvement in his pain; he also received 2l ivf, zofran and clindamycin for ? lung abscess. he also received 2l ivf for hypercalcemia. patient was originally admitted to omed service, but while in the ed he converted from sinus rhythm to atrial fibrillation with rapid ventricular response. patient initially had hr in 160s. he received 15 mg iv diltiazem and his blood pressure dropped to systolic bp of 80. he reecived an additional 1l ns and his sbp improved to 110s. he was started on diltiazem gtt and transferred to icu. on arrival to the micu, patient denies chest pain and shortness of breath. his shoulder and neck pain are well controlled as long as he does not move. he endorses recent 12 pound weight loss. no fevers or chills. no nausea, abdominal pain. no cough. review of systems: (+) per hpi (-) denies fever, chills, night sweats. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies rashes or skin changes. past medical history: oncology history 79-year-old man with a history of copd and a pet avid left upper lobe nodule that has has grown since [**2173**], in the setting of diffuse lad. mr. [**known lastname 14535**] has had multiple conversations with several pulmonary and oncology providers in the last several years recommending tissue biopsy and bone marrow biopsy; but he refused on multiple occasions. noted to have lad in [**2172**]; at that time heme-onc was concerned for primary lung cancer versus a potential lymphoma, less likely melanoma, and recommended a bone marrow biopsy and a surgical biopsy, both of which mr. [**known lastname 14535**] declined. . imaging revealed growth of the spiculated lul nodule [**2172**]-[**2175**] to 2.4 cm, with osteolytic lesion in t5, t6, and posterior sixth left rib thought to be likely mets. on [**2176-8-14**] cxr left upper lobe lung nodule has grown to nearly 7 cm, abuts the anterior surface of the left hilus; he refused biopsy again so his pulmonologist obtained sputum sample.on [**2176-8-28**] sputum cytology revealed highly atypical squamous cells suspicious for squamous cell carcinoma. the patient has refused biopsy and therefore is not eligible for any potential treatments for this presumed malignancy past medical history: melanoma excised from his right thumb removed in [**2172**], no pathology report copd bullous skin disease followed by dermatology htn cva s/p r cea social history: lives alone. has involved daughter - [**name (ni) **] [**telephone/fax (1) 14536**]. quit smoking 13 years ago, 40 + pack years family history: noncontributory physical exam: admission exam: vitals: 98.1, 159, 92/57, 22, 91% on ra general: alert, awake, cachetic appearing elderly gentleman, comfortable, in no acute distress. heent: temporal wasting, sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: tachy, irregular, s1, s2 lungs: diminished breath sounds on left, diffuse rhonchi abdomen: scaphoid abdomen, + bs, soft, non-tender, non-distended gu: foley catheter ext: thin extremities, no clubbing/cyanosis/edema neuro: cnii-xii grossly intact, 5/5 strength upper/lower extremities discharge exam: o: w 103.8 pounds t 98 bp 114/77, 71, 18, 99ra general: alert, awake, wasted appearing elderly gentleman in nad, heent: mmm, oropharynx clear, eomi, perrl neck: supple, jvp 6cm, no lad cv: regular, nl s1, s2, [**3-25**] crescendo murmur heard best at rusb, and left lower sternal border radiating to the axilla. lungs: decreased rhonchorous breath sounds on the left throughout compared to the right. scattered rhonchi on the right. abdomen: scaphoid abdomen, + bs, soft, non-tender, non-distended gu: foley catheter ext: thin extremities, 2+ edema neuro: cnii-xii grossly intact, 5/5 strength upper/lower extremities pertinent results: admission labs: [**2177-6-5**] 06:00pm blood wbc-3.7* rbc-3.02* hgb-8.3* hct-27.5* mcv-91# mch-27.3 mchc-30.0* rdw-19.0* plt ct-110* [**2177-6-5**] 06:00pm blood neuts-64.8 lymphs-24.3 monos-4.5 eos-5.9* baso-0.4 [**2177-6-6**] 12:04am blood pt-13.7* ptt-34.8 inr(pt)-1.3* [**2177-6-5**] 06:00pm blood glucose-114* urean-43* creat-1.9* na-139 k-4.5 cl-106 hco3-24 angap-14 [**2177-6-6**] 12:04am blood ck-mb-1 ctropnt-<0.01 [**2177-6-6**] 12:04am blood ck(cpk)-17* [**2177-6-5**] 06:00pm blood calcium-12.1* phos-2.4* mg-1.9 [**2177-6-6**] 12:04am blood tsh-3.1 [**2177-6-5**] 06:09pm blood lactate-2.4* [**2177-6-6**] 12:16am blood lactate-1.2 relevant labs: [**2177-6-6**] 12:04am blood ck-mb-1 ctropnt-<0.01 [**2177-6-7**] 07:30am blood ctropnt-<0.01 probnp-6616* [**2177-6-6**] 12:04am blood ck(cpk)-17* [**2177-6-6**] 12:04am blood albumin-2.8* calcium-10.7* phos-2.3* mg-1.7 [**2177-6-8**] 07:40am blood calcium-10.5* phos-2.7 mg-1.6 [**2177-6-6**] 12:04am blood tsh-3.1 [**2177-6-7**] 07:30am blood pth-7* [**2177-6-7**] 07:30am blood cortsol-19.7 [**2177-6-8**] 08:38am blood lactate-1.5 discharge labs: [**2177-6-8**] 07:40am blood wbc-4.8 hct-30.1* [**2177-6-9**] 05:25am blood glucose-81 urean-29* creat-1.3* na-137 k-4.0 cl-105 hco3-24 angap-12 [**2177-6-9**] 05:25am blood calcium-9.9 phos-2.3* mg-1.5* microbio: urine culture negative blood culture x 2: no growth to date mrsa screen ([**6-6**]): negative studies: head ct w/o contrast ([**6-5**]): impression: no acute intracranial process. prior right frontoparietal infarct. spine ct w/o contrast ([**6-5**]): impression: 1. no acute cervical fracture or malalignment. 2. multilevel severe degenerative changes of the cervical spine as detailed above. cxr ([**6-5**]): findings: pa and lateral radiographs of the chest demonstrate a previously 5.8 x 3.6 cm left upper lobe lung mass, now measuring 8.7 x 6.5 cm with interval cavitation and a new air-fluid level, which presumably represents a cavitated bronchogenic carcinoma with necrotic contents. superimposed infection cannot be excluded. this lesion abuts the anterior left hilus. no pleural effusion or pneumothorax is detected. the cardiac silhouette is normal in size. the mediastinal and hilar contours are within normal limits. the aortic knob is partially calcified without dilatation. cxr ([**6-7**]): impression: ap chest compared to [**6-5**]: slight increase in the heart size and heterogeneous opacification at the lung bases could be due to dependent edema, but raises more concern for pneumonia. the large cavitated mass in the left upper lobe contains a fair amount of fluid. there is the possibility of internal aspiration. no pneumothorax or appreciable pleural effusion is present. echo ([**6-6**]): there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis (valve area 1.2-1.9cm2). trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is a very small pericardial effusion. there are no echocardiographic signs of tamponade. brief hospital course: patient is a 79 year-old gentleman with history of melanoma, presumptive squamous cell lung cancer with cxray revealing enlargening cavitated bronchogenic carcinoma with necrotic contents, and known osteolytic and osteoblastic lesions in the t-spine most likely from metastases presenting with pain, malaise, and falls at home, transferred to icu for a. fib with rvr which resolved with amiodarone. # altered mental status/encephalopathy: pt's mental status reportedly worsened in the setting of having his fentanyl patch increased from 25mcg to 50 mcg. moreover, the patient was found to be hypercalcemic and hypotensive on presentation. all three factors likely resulted in his ams, with resolution after decrease of his fentanyl patch, treatment and resolution of his hypercalcemia, and discontinuation of his home blood pressure medications. the patient should refrain from having increased fentanyl patch doses. infectious work-up was negative. # atrial fibrillation: patient with no known history of atrial fibrillation, developed a. fib with rvr and rate related ekg changes. precipitant unclear, but possibly etiology includes chronic disease (pt with h/o htn), pulmonary disease (patient with known copd), irritation of left atria from left lung mass, and echo revealing mild lvh, mild mr and as, so patient is good substrate. patient with rate related ekg changes that went away with better rate control. no chest pain, no dyspnea. cardiac markers normal and tsh wnl. in er was started on diltiazem gtt but became hypotensive so was admitted to the micu and started on an amiodarone gtt with a loading dose. rates better controlled with this but bp still low so amio stopped on am of [**6-6**] and pt returned to nsr. echo with mild as and small pericardial effusion without tamponade (likely malignancy related). given the patient's goals of care and falls at home, anticoagulation was not pursued. the patient's care is focused on comfort. the patient may continue his aspirin 325 mg. # hypotension: patient initially admitted to the micu for hypotension (and afib with rvr) which seemed to have developed in the setting of starting a diltiazem drip. responded to ivf but reocurred later with amiodarone drip. given more fluids and bp fine although low once amio/dilt were stopped. did not require pressors during icu stay. the patient was transferred to the floor. his blood pressures were within normal limits throughout his stay off the multi-drug hypertension regimen he was on at home. the patient states he takes too many medications, does not want to take htn medications, and his blood pressures were persistently in the 100s-140 range. he states that he used to have sbps in the 200s and felt fine. he should not be treated for his hypertension unless he requests it, becomes symptomatic, or sbps>200. initiating medications for htn should be discussed with the patient. am cortisol level wnl. # pain: patient with increasing pain of his shoulders and neck, receiving increasing doses of fentanyl patches without adequate relief. pain possibly secondary to malignancy. no evidence of fracture on ct c-spine. started on standing tylenol and contact[**name (ni) **] pcps office who confirmed home fentanyl patch had recently been uptitrated to 50mcg/hr q72hrs. rn at pcps office said that patient had increasing issues with confusion and falls on this higher dose and they were concerned that it was too much narcotic for him. in micu pt placed on fentanyl patch at 25mcg/hr and given prn oxycodone for breakthrough. pain remained reasonably well controlled. given the patient's desire to avoid confusion and his 1 to higher doses of fentanyl beyond his current dose of 25 mcg/hr, the patient was placed on standing tylenol and a lidocaine patch. he should also be given ibuprofen 200-400 mg q4-6h prn for pain before being given oxycodone as his renal function tolerates. notably, the patient's focus is on having clear mentation over pain control, so care should be taken before administering the low dose opiates. #cavitary lung mass most likely from squamous cell carcinoma - pt with history of melanoma but the lung mass appears to be primary squamous cell lung carcinoma. the patient has past sputum cytology with highly atypical squamous cells suspicious for squamous cell carcinoma which in setting of appearence on imaging and hypercalcemia is most consistent with lung cancer. the diagnosis and stage are unknown because the patient refuses biopsy and further work-up. these have been clearly stated in his records here as well as via discussion with the patient and his family on this admission. palliative care engaged in open discussion with patient and confirmed his goals of care. the patient understands the potential for his course of disease to worsen. the patient requests to be dnr/dni with plans for no aggressive care and focus on comfort and quality of life. # hypercalcemia: patient with elevated calcium to 12.3 (corrected ca2+=13.1) and low phos. patient with known lytic and blastic lesions in thoracic spine. pt was given ns for this with improvement. a pth was appropriately low. the patient was given pamidronate 60 mg on [**6-7**] with improvement in calcium, 9.9 on discharge. pamidronate can be repeated as needed at least a week after initial dose. # acute kidney injury: creatinine increased to 1.9, up from most recent baseline of 1.2. likely hypovolemic secondary to poor po intake. creatinine improved with fluids. the patient was briefly diuresed for his lower extremity edema which resulted in a rise in his creatinine from 1.4 to 1.6. subsequent diuresis was held with improvement of his creatinine to 1.3 at discharge. the patient is very volume sensitive/preload dependent likely from his diastolic dysfunction from lvh and aortic stenosis. thus, if diuresis is initiated for his swelling, it should be done carefully and gingerly with close eye on renal function. # acute on chronic diastolic chf: patient with 2+ swelling of lower extremities. there is likely an element of decreased oncotic pressure as well given the patient's low albumin. patient's bnp was 6600 and echo revealed mild lvh, mr, and as, and mild pulmonary artery systolic hypertension. lvef was well preserved. the patient was tried on two doses of iv lasix with improvement in volume status but worsened renal function. the patient is likely quite preload dependent, and thus if diuresis is given, it should be gently. #hypertension, benign: patient with history of poorly controlled hypertension on six anti-hypertensives. no evidence of hypertension here. pt with excellent blood pressure control despite all medications being discontinued. patient states he previously had sbps in 200s without any symptoms and not on medications. he does not wish to take any htn meds and wants to keep his medical list simple. #copd: patient with 40 pack year smoking history and history of copd, but no dyspnea, no wheezing. continued on homoe spiriva #cva s/p r cea: continue aspirin and lipitor #code status: dnr/dni - emphasis on quality of life and limiting procedures. future hospitalizations should be discussed with patient. transitional: 1) the patient's priority is to maintain a clear mental status. as such, we have started ibuprofen in order to help with pain without using opiates, but the patient's renal function should be monitored carefully with nsaid use. 2) the patient also wants his pain well controlled, but is more concerned about maintaining a clear mental status 3) pamidraonte was given here on [**6-7**] for osteolysis of his spine from his malignancy. it can be retreated as needed as long as it is 7 days after previous dose 4) the patient states that he would like discussion before hospitalization in the future. he may not want to be hospitalized depending on the situation 5) the patient states he does not want to go home. he would feel more comfortable with people taking care of him. he currently lives alone. after rehab, there will need to be ongoing discussion with patient and family about where he should go, as he feels that he cannot take care of himself. he currently lives alone at home, with nurses that come just a few times a week. 6) notable labs on last check: hct 30.1, bun 29, cr 1.3. medications on admission: - med list confirmed with pcp office am of [**6-6**]: -> doxazosin 4mg daily -> lipitor 10mg daily -> asa 325mg daily -> clonidine 0.3mg xr daily -> fentanyl patch 50mcg/hr q72hrs (recently uptitrated at home and patient had been confused ever since this increase) -> nifedipine xl 120mg daily -> labetalol 1000mg [**hospital1 **] -> hctz 50mg daily -> enalapril 10mg [**hospital1 **] discharge medications: 1. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 2. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 3. acetaminophen 500 mg tablet sig: two (2) tablet po tid (3 times a day). 4. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 5. oxycodone 5 mg capsule sig: 0.5-1 capsule po every 4-6 hours as needed for pain: only if refractory to ibuprofen, fentanyl, tylenol. watch out for sedation, confusion. 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. senna 8.6 mg capsule sig: one (1) tablet po bid (2 times a day) as needed for constipation. 8. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily): 12 hours on, 12 hours off. 9. bisacodyl 5 mg tablet, delayed release (e.c.) sig: [**1-20**] tablet, delayed release (e.c.)s po daily (daily) as needed for constipation. 10. ibuprofen 200 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. 11. aspirin 325 mg daily discharge disposition: extended care facility: [**hospital3 2558**] - [**location (un) **] discharge diagnosis: primary: altered mental status, afib with rvr, acute kidney injury, hypercalcemia, acute on chronic diastolic heart failure secondary: presumptive squamous cell lung cancer, pain, mild as discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. [**known lastname 14535**], it was a pleasure taking care of you at [**hospital1 18**]. you were admitted for confusion and falls. this may have been related to the increase in your fentanyl patch dose or your high calcium. this resolved with decrease of fentanyl dose back to your previous dose and improvement of your calcium with a drug called a bisphosphonate. you also developed atrial fibrillation. this improved with medications and resolved and did not occur again. we clarified your goals of care which include priorities of: 1) maintaining a clear mental status 2) controlling pain. the priority is on maintaining a clear mental status over controlling pain for now. your kidney function and blood pressures were initially low, but this improved with hydration. the following changes were made to your medications: stop doxazosin stop clonidine stop nifedipine stop labetalol stop hydrochlorothiazide stop enalapril decrease fentanyl to 25 mcg patch/hr q 72 hours start lidocaine patch for shoulder and hip pain start ibuprofen 200-400 mg q4-6h prn for pain start oxycodone for pain start bowel regimen with senna, colace, bisacodyl followup instructions: please have your rehab facility schedule an outpatient follow up appt with: name: [**last name (lf) **],[**first name3 (lf) **] l. location: [**hospital1 **] healthcare - [**location (un) **] address: [**state 4607**], [**location (un) **],[**numeric identifier 588**] phone: [**telephone/fax (1) 4606**] completed by:[**2177-6-10**]",0
3,"admission date: [**2112-7-2**] discharge date: [**2112-8-11**] date of birth: [**2045-12-30**] sex: m service: medicine allergies: no known allergies / adverse drug reactions attending:[**first name3 (lf) 7591**] chief complaint: fever, hypotension major surgical or invasive procedure: [**2112-7-2**] intubation history of present illness: mr. [**known lastname 34698**] is a 66 year old man with h/o poems syndrome, s/p autosct [**12-15**], therapy-related mds, recently hospitalized and diagnosed with recurrence of poems syndrome, c1d18 of velcade/dexamethasone, who was admitted with fever and hypotension. the patient was discharged 2 days prior to admission ([**2112-6-30**]) after hospitalization for febrile neutropenia, complicated by arf requiring hdx4 sessions and features of poems syndrome relapse. at home, the patient had a low grade temp yesterday to 100.3 with chills and then another fever to 101.2 this afternoon. the wife notes that he was complaining of increased pain in his lower extremities (neuropathy) and had decreased po intake. he became increasingly lethargic and weak to the point that they had difficulty getting him out of bed. his urine output decreased from 1100cc the day before to 400cc over 24h. foley was in place since last sunday (1 week). the wife called the bmt fellow on call, who referred the patient to the ed. in the field, the patient's bp was 60/40. ems placed a peripheral line and bolused him with ivf. in the ed, initial vs were: t 101.2 hr 120 bp 184/132 rr 18 o2sat 100% nrb. bp then dropped to 50/30 about 10 minutes after arrival. the patient was lethargic, but arousable to voice, complaining of generalized body pains. patient had brown, turbid urine in his foley. cxr showed persistent l basilar opacification. labs notable for hct 19.5, plt 8, hco3 18, cr 3.7. the patient was started on levophed, vanc, and cefepime. also given a dose of hydrocortisone given recent steroid use. given 4l ns. he was intubated in the ed without difficulty using the bougie, despite h/o tracheal stenosis, and started on fent/midaz for sedation. on transfer, levophed was running at 0.42mcg. vs: t 100 hr 119 bp 114/51 rr 18 o2sat 99% on fio250% tv450 peep4. on arrival to the micu, patient's vs t 98.6 hr 106 bp 127/84 rr 16 o2sat 98% on ac tv 450 rr 18 fio2 40% peep 5. the patient is intubated and sedated on fentanyl 100mcg/hr, midazolam 4mg/hr, levophed 0.32mcg/kg/min. past medical history: oncologic history: poems syndrome manifested by polycythemia, polyneuropathy, organomegaly, endocrinopathies including hypocalcemia, hypothyroidism, hypogonadism and elevated pth (diagnosed in [**2099**]). in [**2101**] anasarca that eventually progressed to respiratory failure, treated with plasmapheresis and prednisone followed by 18 months of cyclophosphamide. [**4-/2108**]/[**2108**]: bortezomib (1.3 mg/m2 days 1,4,8,11 and dexamethasone (20 mg days 1,2,4,5,8,9, 11, and 12) x three cycles discontinued due to painful lower extremity neuropathy. [**11/2108**] high dose cytoxan for stem cell mobilization ([**11/2108**]) [**12/2108**] high dose melphalan with stem cell rescue ([**2108-12-9**]) in remission since than. [**4-/2112**]: bone marrow aspirate and biopsy showed dysplastic basophilic and polychromatophilic erythroblasts, a marked left shift and dysplastic myelopoiesis and abundant hyperchromic megakaryocytes, which initially were felt to be consistent with colchicine toxicity; however, chromosome studies performed on that bone marrow material revealed an abnormal karyotype 15/16 studied cells showed a complex clone with the following anomalies. he had deletion in the long arm of chromosome 5 between band 5q13 and 5q33, otherwise known as 5q minus. he had monosomy 13, monosomy 17, monosomy 20, and addition of an unidentified marker chromosome and [**2-12**] double minute chromosomes. these were all consistent with a myeloid abnormality since there were not an increased number of blasts much more consistent with mds. other past medical history: 1. poems syndrome: first diagnosed in [**2099**] with treatment described above. his manifestations have been as follows: a. polyneuropathy - cidp in [**2099-6-6**]; painful lower extremity sensory neuropathy and proprioception defects. b. organomegaly - splenomegaly c. endocrinopathy - hypothyroidism, hypogonadism, hypocalcemia related to hypoparathyroidism d. monoclonal gammopathy e. skin and nail changes - now resolving. f. pulmonary hypertension and restrictive lung disease. g. chronic renal insufficiency (which has now resolved with therapy) h. anasarca, now resolved. i. hyperuricemia and gout - now resolved j. polycythemia and thrombocythemia - now resolved 2. vitamin b12 deficiency 3. s/p compound fracture, [**2103-8-7**] 4. s/p tracheostomy [**2101**] 5. prostate cancer s/p brachytherapy 6. gout 7. pulmonary htn and restrictive lung disease 8. chronic kidney disease 9. c dif ([**5-/2112**]) 10. acute angle glaucoma ([**2112-4-27**]) social history: pt is a ukrainian refugee who immigrated to the us in [**2049**]. he lives with his wife and they have two sons. [**name (ni) **] cigarettes, very occasional alcohol. he works as a paint salesman for [**last name (un) 34699**]-[**location (un) 805**]. he is also a [**country 3992**] veteran. exposed to [**doctor last name **] [**location (un) **], which he believes is the etiology of his poems. family history: mother is alive and has sle, fibromyalgia. his father's medical history is unknown. half-sister with ovarian cancer. physical exam: admission exam vs: tm 98.7, tc 98.7, p 98 (98-106), bp 117/70 (117/70 - 127/84), rr 16 spo2: 98%, fio2: 40% ventilator mode: cmv/assist/autoflow, vt: 450 ml, rr : 18, peep: 5 cmh2o general: intubated, sedated heent: sclera anicteric, pupils minimally reactive to light, l>r neck: supple, jvp not elevated, no lad cv: tachycardic, s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation anteriorly with decreased breath sounds at the bases abdomen: soft, non-distended, bowel sounds present gu: foley with brown, turbid urine ext: warm, well perfused, 2+ pulses, 2+ generalized edema/anasarca neuro: sedated discharge physical exam: 98.1, 120/68, 74, 18, 98ra general: aaox3 in nad, [**last name (un) 4969**] appearing male older than stated age heent: pupils are asymmetric at baseline l>r neck: previous scar from trach is well healed, no elevated jvp no lad lungs: ctab moving good air bilaterally cv: rrr, 2/6 systolic murmur heard best at hte lusb not radiating abd: mildly protuberant, normoactive bowel sounds, soft, nontender, no palpable masses ext: warm, well perfused, trace peripheral edema bilaterally skin: two stage 1 ulcers. one located on the right buttock with some underlying edema, and one located on the right posterior posterior heel neuro: cn ii-xii intact. motor 3/6 strength in ue and le bilaterally. decreased proximal strength biltaerally int he lower extremiteis. sensation grossly intact and symmetric. occasional intentional tremulous not orthostatic, patient is symptomatic upon standing but by 5min patients vs are stable. pertinent results: admission labs [**2112-7-2**] 08:40pm blood wbc-3.4* rbc-2.16* hgb-6.3*# hct-19.5* mcv-90 mch-29.2 mchc-32.4 rdw-15.1 plt ct-10*# [**2112-7-2**] 08:40pm blood neuts-54 bands-10* lymphs-5* monos-30* eos-0 baso-0 atyps-0 metas-0 myelos-1* [**2112-7-2**] 08:40pm blood pt-13.5* ptt-22.8* inr(pt)-1.3* [**2112-7-2**] 08:40pm blood glucose-71 urean-75* creat-3.7*# na-133 k-4.2 cl-101 hco3-18* angap-18 [**2112-7-2**] 08:40pm blood alt-47* ast-32 ld(ldh)-219 alkphos-272* totbili-1.1 [**2112-7-2**] 08:40pm blood ctropnt-0.06* [**2112-7-3**] 04:24am blood ck-mb-4 ctropnt-0.07* [**2112-7-3**] 09:48am blood ck-mb-3 ctropnt-0.08* [**2112-7-2**] 08:40pm blood albumin-2.8* [**2112-7-3**] 04:24am blood calcium-6.5* phos-5.3*# mg-1.5* [**2112-7-2**] 09:08pm blood lactate-2.2* micro [**2112-7-2**] urine culture (final [**2112-7-4**]): no growth. [**2112-7-2**] blood culture, routine (preliminary): staphylococcus species. aerobic bottle gram stain (final [**2112-7-3**]): gram positive cocci in pairs and clusters. anaerobic bottle gram stain (final [**2112-7-4**]): gram positive cocci in pairs and clusters. [**2112-7-2**] blood culture, routine (pending): [**2112-7-3**] sputum source: endotracheal. gram stain (final [**2112-7-3**]): [**12-1**] pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (preliminary): rare growth commensal respiratory flora. [**2112-7-3**] blood culture: neg [**2112-7-4**] blood culture, neg [**2112-7-4**] blood culture, neg urine studies: [**2112-7-20**] 06:05am urine casthy-20* castbr-2* [**2112-7-9**] 02:09pm urine histoplasma antigen-test [**2112-7-11**] 04:57pm urine bk virus by pcr, urine-test [**2112-7-11**] 06:23am urine u-pep-multiple p ife-no monoclo [**2112-7-27**] 09:13am other body fluid wbc-650* rbc-[**numeric identifier **]* polys-2* bands-1* lymphs-12* monos-26* mesothe-1* macro-58* urine: [**2112-8-8**] 05:30pm urine color-yellow appear-clear sp [**last name (un) **]-1.012 [**2112-8-8**] 05:30pm urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-neg [**2112-8-8**] 05:30pm urine rbc-1 wbc-2 bacteri-none yeast-none epi-1 imaging [**2112-7-2**] chest (portable ap): persistent left basilar opacification may represent atelectasis, pneumonia or aspiration. moderate-sized left and small right bilateral pleural effusions. possible mild pulmonary vascular congestion, though evaluation is somewhat limited due to low lung volumes. [**2112-7-4**] chest (portable ap): there is an endotracheal tube and a feeding tube which are unchanged in position. there is also a right-sided central venous line with the distal lead tip in the cavoatrial junction, unchanged. there is unchanged cardiomegaly. there is a left retrocardiac opacity and left-sided pleural effusion which is stable. no overt pulmonary edema is identified. overall, there has been no significant change. [**2015-7-8**]: ct abd/pelvis: impression:1. no new fluid collection or source of intra-abdominal infection. 2. stable bilateral small to moderate partially loculated pleural effusions slightly improved since [**2112-6-11**]. [**2112-7-11**]: ruq u/s impression: 1. no evidence of portal venous thrombosis. 2. no hepatobiliary pathology. 3. borderline spleen size. [**2112-7-17**]: ct chest impression: 1. progression of left lower lobe consolidation, and increase in size in bilateral loculated pleural effusions with enhancing pleura, concerning for pneumonia and/or empyema. 2. cardiomegaly. 3. heterogeneous enhancement of the kidneys, bilateral, raises possibility of pyelonephritis or infarct, recommend correlation with ua. [**2112-7-27**]: bronchial washing: bronchial lavage: negative for malignant cells. pulmonary macrophages and blood. no viral cytopathic changes or fungal organisms are seen. [**2112-7-29**]: hip xray:views of both hips show minimal hypertrophic spurring with slight narrowing of the joint spaces bilaterally. multiple metallic seeds are seen in the region of the prostate. [**2112-8-2**]: ultrasound right buttock: persistent mild edema of the soft tissue overlying the right buttock. no drainable collection identified. discharge labs [**2112-8-11**] 12:00am blood wbc-2.3* rbc-2.37* hgb-7.2* hct-21.7* mcv-92 mch-30.3 mchc-33.1 rdw-14.3 plt ct-40* [**2112-8-11**] 12:00am blood neuts-30* bands-0 lymphs-47* monos-19* eos-0 baso-0 atyps-0 metas-0 myelos-4* [**2112-8-11**] 12:00am blood pt-10.3 ptt-22.7* inr(pt)-0.9 [**2112-8-11**] 12:00am blood glucose-130* urean-37* creat-0.6 na-137 k-4.4 cl-101 hco3-28 angap-12 [**2112-8-11**] 12:00am blood alt-52* ast-24 ld(ldh)-293* alkphos-391* totbili-0.4 [**2112-8-11**] 12:00am blood calcium-8.6 phos-3.0 mg-1.8 brief hospital course: primary reason for admission: mr. [**known lastname 34698**] is a 66 year old man with h/o poems syndrome, s/p autosct [**12-15**], therapy-related mds, recently hospitalized and diagnosed with recurrence of poems syndrome, s/p velcade/dexamethasone, who was admitted with fever and hypotension and requiring intubation initially who was found to have b+glucan hemoptysis and multiple episodes of febrile neutropenia requiring multiple icu stays who is currently hemodynamically stable and afebrile x 1 week still requiring occasinal blood transfusions/platelet transfusions at the time of discharge. active issues: #poems- patient with recent diagnosis of poems syndrome relapse velcade/dexameth (d1 [**6-16**]). during this admission he was initially treated with high dose short course of steroids. his pain was controlled with the addition of increased gabapentin, addition of methadone and oxycodone. as his pain would worsen when the steroids were weaned off, he was kepts on 3mg po dexamethasone as a stable dose for one week prior to discharge. while he was on a sliding scale due to being on steroids, he did nto require any insulin and therefore this was stopped at the time of discharge as he was on a stable regimen of steroids. -will require follow-up with dr. [**last name (stitle) 410**] for ongoing care for this -will continue dexamethasone 3mg po bid #mds- patient has history of therapy related mds. his smear during this hospitalization continued to show atypical cells. during this hospitalization he required multiple blood transfusiosn and platelet transfusions and for a period of time was transfusion dependent. he had no adverse reactions to any of his blood product transfusions. he was started on revlimid on [**8-2**] and tolerated this well. he will continue on this after he leaves. -will require frequent lab work to determine if transfusions are required -will continue revlimid 10mg po qday #dysuria- patient has significant dysruia and negative ua with unclear source of the pain. -continue methadone, oxycodone -continue oxybutinin, pyridium and urojets as needed for the pain -consider urology consult if persists neutropenic fevers- no clear source of his fevers. he was found to have hemoptysis and was bglucan positive so was started on voricanozole and continues this at the time of discharge.he was on iv vancomycin and meropenem and these were weaned off in the week prior to discharge and he was switched to ciprofloxacin 500mg po bid a few days prior to discharge and remained afebrile with stable wbc. -continue voricanozole -continue ciprofloxacin # respiratory failure: patient was intubated in the ed to allow for aggressive volume resuscitation. he was extubated without problem and has no oxygen requiremnet at the time of discharge. his lungs are clear on exam. . # acute kidney injury: patient had elevated cr to 3.7 at the beginning of his admission which was a combination of prerenal and atn. this responded to fluids and resolved prior to his discharge. . # elevated troponin: pt had three sets of elevated troponins (0.06, 0.07, 0.08) but ck-mbs were normal. he also had some initial ekg changes that resolved. he likely had some demand ischemia in the setting of [**last name (un) **]. he was chest pain free throughout his course . # anemia: patient is transfusion-dependent [**3-10**] to mds. hct 19.5 on admission, and was transfused 2 units prbcs with an appropriate bump in his hct, which subsequently trended down. he continued to require intermittent transfusions throughout his course. last platelet transfusion on [**2112-8-9**] last prbc transfusion on [**2112-8-11**] . # hyperbilirubinemia: t bili and direct bili were elevated. the rest of his lfts were unremarkable, demonstrating a cholestatic picture. a right upper quadrant u/s was performed that showed no evidence of cholestasis. his alk phos continued to uptrend during the end of his hosptial stay with no localizing symptoms. -this will be monitored by dr.[**doctor last name **] office # volume overload: secondary to new left ventricular dysfunction and acute systolic heart failure as well as poems syndrome with likely capillary leak, hypoalbuminemia, and initial aggressive volume resuscitation. patient was grossly volume overload after his resuscitaion which had resolved at the time of discharge without an elevated jvp or peripehral edema. transitional issues: -patient to receive his own revlimid while at rehab 10mg po qday -pain control- patient is currently on methadone and oxycodone, please monitor for any changes needed -[**name (ni) 34700**] unclear source, on multiple medications medications on admission: ([**2112-6-30**] d/c summary): levothyroxine 112mcg po daily acyclovir 400mg po qhs pyridoxine 100mg po daily doxazosin 8mg po daily vitamin b12 2000mcg po daily thiamine 100mg po daily oxycodone-acetaminophen 5-325mg 1-2tabs po q6h prn calcium carbonate 500mg po bid allopurinol 100mg po daily timolol maleate 0.5% 1gtt [**hospital1 **] citalopram 10mg po daily sulfamethoxazole-trimethoprim 400-80mg po daily gabapentin 300mg po q12h discharge medications: 1. levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). 2. acyclovir 400 mg tablet sig: one (1) tablet po q8h (every 8 hours). 3. vitamin b-12 2,000 mcg tablet extended release sig: one (1) tablet extended release po once a day. 4. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 5. calcium carbonate 500 mg calcium (1,250 mg) tablet sig: one (1) tablet po twice a day. 6. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 7. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 8. gabapentin 300 mg capsule sig: two (2) capsule po q12h (every 12 hours). 9. midodrine 2.5 mg tablet sig: one (1) tablet po tid (3 times a day). 10. dexamethasone 1.5 mg tablet sig: two (2) tablet po q12h (every 12 hours). 11. methadone 5 mg tablet sig: [**2-8**] tablet po qam (once a day (in the morning)). 12. methadone 5 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)): give 12 hours after am methadone dose. 13. oxycodone 5 mg tablet sig: one (1) tablet po q2h (every 2 hours) as needed for severe pain: hold for sedation or rr<10. 14. phenazopyridine 100 mg tablet sig: one (1) tablet po tid (3 times a day) for 2 days. 15. oxybutynin chloride 5 mg tablet sig: one (1) tablet po tid (3 times a day). 16. lidocaine hcl 2 % gel sig: one (1) appl mucous membrane tid (3 times a day) as needed for penile pain. 17. terazosin 1 mg capsule sig: two (2) capsule po hs (at bedtime). 18. revlimid 10 mg capsule sig: one (1) capsule po daily (daily): patient to take own medication. 19. voriconazole 200 mg tablet sig: two (2) tablet po q12h (every 12 hours). 20. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 21. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 22. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 23. hydrocortisone 2.5 % cream sig: one (1) appl rectal daily (daily). 24. ondansetron 8 mg film sig: one (1) film po every 4-6 hours as needed for nausea. 25. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours). discharge disposition: extended care facility: [**hospital1 700**] - [**location (un) 701**] discharge diagnosis: primary: poems, severe sepsis, respiratory failure, mds secondary: bph, type ii diabetes mellitus discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. [**known lastname 34698**], you were admitted to the hospital because you were very short of breath and having fevers. this required you to be in the icu, and after you improved you were transferred to the regular oncology floor. here we worked to help manage your pain and treat your fungal pneumonia with iv antibiotics. on a couple of occasions your blood pressure got low and you were feverish and were treated in the icu for this. as you were here for a prolonged hospitalization you will require intensive rehab to get your strength back and will do this at [**hospital1 **]. while you were here you received multiple blood and platlet transfusions while your counts were low without problems. transitional issues: pending labs/studies: none medications started: voricanozole (antifungal) ciprofloxacin (antibiotic) revlimid dexamethasone oxycodone (as needed pain medication) methadone (pain medication twice a day) senna colace oxybutinin (help with bladder spasm) terazosin (help with bph) pyridium (help with pain on urinating) urojet (numbing medicine for pain with urinatng) midodrine- (for dizziness on standing) ondansetron- as needed for nausea medications changed: increased citalopram from 10mg once a day to 20mg once a day increased gabapentin from 300mg to 600 mg medications stopped: stopped allopurinol stopped doxazosin (on terazosin instead) stopped timolol eye drops (no longer needed) stopped percocets (on oxycodone and methadone instead) follow-up needed for: 1. determine course of antibiotics and antifungals (dr. [**last name (stitle) 410**] 2. monitoring your blood counts and your liver function tests 3. you will need to follow-up with dr. [**last name (stitle) **] to determine if you need your glaucoma drops again followup instructions: will we contact you with your appointment times and dates! if you do not hear from us within 48hours please contact us [**telephone/fax (1) 3241**]",0
4,"admission date: [**2102-5-15**] discharge date: [**2102-5-17**] date of birth: [**2051-2-6**] sex: m chief complaint: chief complaint was question choreoathetosis. history of present illness: the patient is a 51-year-old patch 50 mcg per hour, who states he took benadryl the evening prior to admission and subsequently had uncontrollable arm and leg movements. he went to [**hospital3 15174**]. per the notes there, the patient had complained of back pain and ""itchy feet"" that resolved. the patient was noted to have athetosis. a dr. [**first name4 (namepattern1) **] [**last name (namepattern1) **], and it was felt that the patient could have been having an adverse reaction to the fentanyl and benadryl as a rare side effects of these medications is athetosis. the patient was initially treated with benadryl prior to them discovering that this may have been causing his symptoms with worsening of his symptoms. he then was given ativan for a total of 26 mg. he also received morphine, narcan, and 5 mg of intravenous valium. the patient was noted to have some improvement in his movements, but also developed agitation requiring four-point restraints. he was then transferred to [**hospital1 69**] where he was admitted to the medical intensive care unit. on arrival here, his temperature was 99.2. his other vital signs were stable. it was decided to stop using ativan for his movement disorder, and he was changed to droperidol to block dopamine. at the time of arrival, he denied any pain, and he was unable to recall the events of the evening prior. past medical history: 1. history of vicodin abuse in the past; subsequently on a fentanyl patch. 2. depression. 3. chronic low back pain. 4. question of hepatitis c; which the patient states he obtained secondary to a blood transfusion during parotid surgery. medications on admission: medications at home included a fentanyl patch 50 mcg. allergies: the patient has no known drug allergies. social history: the patient is currently staying with his mother [**name (ni) 41643**] [**name (ni) 41644**] (telephone number [**telephone/fax (1) 41645**]), as he states he is afraid to stay in his own apartment secondary to fears about the insulation causing all of his health problems. [**name (ni) **] smokes one pack of cigarettes per day. he denies any alcohol use. he states that he smoked marijuana in the remote past but denies any current use. he denies any history of intravenous drug use. physical examination on presentation: temperature was 101, blood pressure of 135/66, heart rate of 85, oxygen saturation of 96%. in general, the patient was somnolent but easily arousable to voice. head, eyes, ears, nose, and throat showed the sclerae to be anicteric. pupils were equal, round and reactive to light. extraocular movements were intact. the oropharynx was slightly dry. the neck was supple. there was no jugular venous distention, and no lymphadenopathy. the lungs were clear to auscultation bilaterally. the heart had a regular rate and rhythm. no murmurs, rubs or gallops. the abdomen was soft, nontender, and nondistended. there were normal active bowel sounds. there was no hepatosplenomegaly. the extremities were without clubbing, cyanosis or edema. neurologic examination showed the patient to be somnolent but easily arousable. he was oriented to ""[**hospital3 **]"" and [**2102-5-15**]."" he answered simple questions and moved all extremities. cranial nerves ii through xii were grossly intact. his toes were downgoing bilaterally. deep tendon reflexes were 2+ throughout. pertinent laboratory data on presentation: laboratories from the outside hospital showed a white blood cell count of 7.8, hematocrit of 46.8, platelets of 213. sodium of 139, potassium of 4.1, chloride of 101, bicarbonate of 27, blood urea nitrogen of 16, creatinine of 0.7, blood sugar of 108. calcium of 9.4, albumin of 3.8, alt of 119, ast of 45, alkaline phosphatase of 68. creatine kinase of 451, with a mb index of 1. on arrival to [**hospital1 69**] the patient's sodium was 144, potassium of 4, chloride of 109, bicarbonate of 24, blood urea nitrogen of 15, creatinine of 0.6, blood sugar of 84. alt was 95, ast was 76, amylase of 41, alkaline phosphatase of 59. creatine kinase of 2526, lipase of 6. lithium level was less than 0.2. toxicology screen was positive for barbiturates and opiates. a strychnine level was pending at the time of admission. radiology/imaging: a head ct showed no acute process. hospital course: in summary, the patient is a 51-year-old male who was admitted to the [**hospital1 188**] with what was felt to be an adverse reaction to fentanyl and benadryl administration. he was originally admitted to the medical intensive care unit for observation after he had received a lot of benzodiazepines as well as droperidol. in the medical intensive care unit, the patient was noted to have rising creatine kinases with a negative mb index and an elevated temperature. he was transferred out to the general medical floor on the second hospital day in stable condition with a decreased temperature, and no further abnormal movements. 1. neurology: a neurology consultation was obtained when the patient was first admitted given that he had fever and mental status changes. it was felt that the patient's abnormalities were most likely secondary to a medication reaction, as they promptly resolved after withdrawal of the offending agents. the question of a lumbar puncture was raised, but given the patient's lack of neurologic findings, lack of meningeal signs, and quick resolution of fever without antibiotics, no lumbar puncture was ever obtained. the question of possible neuroleptic malignant syndrome was considered given the patient's clinical presentation. however, the patient adamantly refused taking any neuroleptic medications. the patient's primary care physician was not aware of the patient taking any current neuroleptic medications as well. 2. psychiatry: as stated, the patient was exhibiting delusional behavior. he was preoccupied about formaldehyde insulation that was present in his subsidized apartment. he denied any auditory or visual hallucinations. he stated that he felt like he was depressed but denied any active suicidal ideation, but stated that he did think about hurting himself from time to time but could ""never do it."" he indicated that he had, in the past, been under the care of a psychiatrist. his primary care physician was [**name (ni) 653**] regarding his baseline mental status, and it was found that this has been a long-term issue for him, and that she has seen him three times in the past, and he has exhibited this same type of behavior at her office. in fact, he even brought a sample of powder which he said was the offending [**doctor last name 360**] into her office at one point. a psychiatry consultation was called to assess for the patient's safety to be discharged on the third hospital day. they felt the patient did seem paranoid and delusional but was not at risk of harm to himself or others and was safe to be discharged. they recommended outpatient psychiatric treatment if the patient would agree to it. i spoke to the patient's primary care physician, [**name10 (nameis) **] she stated that she would attempt to get the patient into a program given the findings above. 2. gastrointestinal: the patient also reported a history of hepatitis c that he stated was secondary to a blood transfusion that he received. hepatitis serologies and ultimately came back showing him to indeed be hepatitis c positive. in addition, serologies were consistent with past exposure to hepatitis b with hepatitis b surface antibody and hepatitis b core antibody both positive; but hepatitis b surface antigen negative. the patient's ast and alt were mildly elevated while admitted. he also described a history of a 40-pound to 50-pound weight loss over the past one to two years as well as anorexia and chronic nausea and vomiting. he did not have any stigmata of chronic liver disease on physical examination, however. given his weight loss and long-term history of hepatitis with elevated liver enzymes, there was concern for hepatoma. i spoke with the patient's primary care physician and informed her of the hepatitis serology results as well as the fact that his liver enzymes were elevated. she stated she would get the patient referred to gastroenterology. 3. infectious disease: as stated, the patient had a temperature at the time of admission after he had significant agitation and muscular rigidity secondary to his presumed drug reaction. he never had an elevated white blood cell count. he had been afebrile for more than 24 hours at the time of this discharge summary. there was concern for possible urinary tract infection, as a urine sample which had been sent while a foley was in place showed a significant amount of blood with white blood cells present. however, there were no bacteria seen, and there was a significant amount of red blood cells consistent with trauma from the foley. a repeat urinalysis was sent when the foley was removed, and this showed still blood present but no nitrites and no leukocyte esterase. there were no bacteria seen on microscopy. it was felt that his urine findings were most likely secondary to trauma from the foley and not infection. his cultures have remained negative. blood cultures have remained negative as well. stool cultures were negative for clostridium difficile, salmonella, and shigella. 4. renal: the patient did have a rise in his creatine kinase amount after having his initial episode of agitation and significant thrashing about with injury to his arms and legs when he was in the four-point restraints. his creatine kinases peaked at 8868 on the second hospital day, and on the third hospital day they were trending down. at the time of this discharge summary the most recent creatine kinase was 5569. there was another creatine kinase pending for this afternoon. if it is still trending down, the patient will be discontinued from his intravenous fluids. his renal function had remained stable with a stable blood urea nitrogen and creatinine. 5. communications: the patient's primary care physician [**last name (namepattern4) **]. [**first name4 (namepattern1) **] [**last name (namepattern1) 41646**] (at telephone number [**telephone/fax (1) 41647**]) was [**telephone/fax (1) 653**] throughout the [**hospital 228**] hospital stay and informed of the events which occurred. condition at discharge: condition on discharge was stable. medications on discharge: the patient was to be given a prescription for vicodin one to two tablets p.o. q.6h. p.r.n. for back pain. he was given a prescription for 10 pills. discharge followup: the patient was to follow up with his primary care physician, [**last name (namepattern4) **]. [**last name (stitle) 41646**], within one week following discharge. he will need further evaluation for pain control and possibly a chronic pain unit consultation to help manage his back pain. in addition, he will need follow up for his hepatitis c and elevated liver enzymes. he also needs psychiatric followup of his likely delusional disorder. discharge diagnoses: 1. choreoathetosis secondary to fentanyl/benadryl. 2. hepatitis c. 3. chronic low back pain. 4. delusional disorder. [**first name11 (name pattern1) 4283**] [**last name (namepattern4) 4284**], m.d. [**md number(1) 7551**] dictated by:[**last name (namepattern1) 6859**] medquist36 d: [**2102-5-17**] 13:47 t: [**2102-5-18**] 08:34 job#: [**job number 27843**] cc:[**numeric identifier 41648**]",1
5,"admission date: [**2172-7-31**] discharge date: [**2172-8-20**] date of birth: [**2095-9-18**] sex: m service: medicine allergies: latex / dilantin attending:[**last name (namepattern1) 9662**] chief complaint: sepsis major surgical or invasive procedure: endotracheal intubation mechanical ventilation central line placement skin biopsy foot biopsy history of present illness: this is a 76 year old gentleman with a history of ischemic cardiomyopathy (ef 20-30, aicd), niddm, ckd, chronic atrial fibrilation (not on coumadin because of prior fall and small head bleed) who is being transferred from the [**hospital3 3583**] icu for sepsis of unclear origin on pressors. current course of events begins when he was admitted to [**hospital1 3325**] back in [**month (only) 205**] for a nonhealing right foot ulcer after failing outpatient course of doxycycline. patient has a history of nonhealing foot ulcers (including 1 on left requiring amputation of left 5th toe in [**2159**]). wound cultures negative but imaging at the time was concerning for osteomyelitis. he was eventually discharged to rehab for 6 weeks of iv vanc/unasyn. he did well during rehab and was ambulatory. only issue which was some mild diarrhea which was c diff negative and a transient skin rash with resolved with topical treatment. less than 24 hours after going home (after completing his course of antibiotics) he returned to the ed with severe malaise, chills, fever and fatigue. on presentation to the osh ed he had a temp of 100.6, was hd stable, o2 sats 96%. labs notable for wbc of 12,000 with 10% bands and [**last name (un) **] with creatinine of 3.1 vs 2.5 the day prior (baseline 1.5-2.5). cxr normal. ua showed 2+ leuk est with 10-20 wbcs, budding yeast, and 1+ bacteria. he did not have an indwelling catheter. he was admitted with possible uti and started on iv cipro. since admission to [**hospital 52510**] hospital he has continued to clinically decline. progressive leukocytosis, fevers up to 104, and worsening [**last name (un) **]. his [**last name (un) **] catheter was removed (tip cultured, routine and fungal cultures still pending as of [**7-31**]). imaging showed evidence of osteomyelitis but overall it appeared his ulcer clinically had improved after extended antibiotics. he developed a progressive diffuse maculopapular rash with associated pruritis. he was transferred to the icu on [**7-29**] for episodic hypotension (to sbps 60s-70s) associated with worsening labs and rash. cipro was stopped and he was started back on vanc/unasyn as well as on iv fluconazole for concerns for systemic fungal infection (recent broad spectrum antibiotics and budding yeast in urine). seen by id (dr. [**name (ni) 52511**]). repeat c diff testing was done which was ultimately negative. hypotension was fluid responsive but after several boluses started neo (due to tachycardia/af/rvr). in the 24 hours prior to transfer (on [**7-31**]) he continued to clinically deteriorate. his antibiotics were changed to daptomycin, aztreonam and voriconazole given concerns for hypersensitivity reaction to prior antibiotics. all urine and blood cultures were negative. while awaiting results of c diff an abdominal ct showed gastric distention without signs of colitis or other intraabdominal source of infection. his diffuse rash persistent. renal was consulted. creatinine continued to rise and he was given further ivf (on home diuretics at baseline for cm). his blood pressures continued to decline and a right ij was placed. initial cvp was 17. he was started on neosynephrine. he continued to have af/rvr. lactate elevated at 2.7. venous saturation 79%. concern raised for aicd infection given progressive course. echo showed ef 25% and no ""obvious sign of infection of cardiac hardware"". no new complaints on the morning of transfer however his labs continued to decline and were notable for a wbc count of 32,000 with 45% bands and a creatinine up to 5.1. lactate unchanged at 2.6. his declining status was discussed with the family and it was decided to transfer him to a tertiary care facility. sbps prior to transfer were in the 60s-70s on neo. he had made only 30cc of urine overnight. during the 24 hours prior to transfer at osh his heart rates have mostly been in 120s, bursts (especially with fevers) to 130s-140s, resolve with treating temperature. on arrival to the micu he was severely ill-appearing and confused. he had no specific complaints but was mumbling words which were unintelligible. within 30 minutes of arrival he reported feeling much better and was alert and oriented to place. review of systems: (+) per hpi (-) denies headache, cough, shortness of breath, chest pain, chest pressure, palpitations, nausea, vomiting, diarrhea, abdominal pain. past medical history: ischemic cardiomyopathy niddm nonhealing foot ulcers af with rvr not on coumadin [**1-16**] prior head bleed ckd baseline 1.5-2.5 cad with prior stent social history: lives at home with wife. quit smoking 25 years ago. quit etoh 30 years ago. worked as a police officer and then baliff. retired in [**2157**]. family history: brother died of mi physical exam: on admission to [**hospital1 18**] vitals: t: 97.2 bp: 81/59 p: 125 rr: o2: 94%/2l general: severely ill-apearing heent: sclera anicteric, mmm, perrl neck: supple, jvp not elevated, no lad cv: tachycardic, no murmurs, rubs, gallops lungs: clear to auscultation anteriorly, no wheezes, rales, ronchi abdomen: soft, obese, mildly diffusely tender, bowel sounds present gu: foley with minimal urine ext: 2+ edema bilaterally, cool, clampy, poorly perfused, palpable pulses bilaterally, left foot eschar, lateral aspect of right foot 5th toe ulcer, deep but without surrounding erythema neuro: alert and oriented to place on discharge: general: nad comfortable heent: sclera anicteric, mmm, perrl neck: supple, jvp not elevated, no lad cv: irregularly irregular, no murmurs, rubs, gallops lungs: clear to auscultation anteriorly, no wheezes, rales, ronchi abdomen: soft, obese, mildly diffusely tender, bowel sounds present, diffusely edematous gu: mildly swollen scrotom, foley with clear yellow urine ext: 2+ edema bilaterally, venous stasis changes, left foot eschar, lateral aspect of right foot 5th toe ulcer neuro: alert and oriented to person, date and place pertinent results: labs on admission to [**hospital1 18**] ============================== [**2172-7-31**] 03:00pm blood wbc-29.9* rbc-3.79* hgb-11.1* hct-35.8* mcv-94 mch-29.3 mchc-31.1 rdw-17.9* plt ct-177 [**2172-7-31**] 03:00pm blood neuts-93.5* lymphs-3.5* monos-1.6* eos-1.2 baso-0.2 [**2172-7-31**] 03:00pm blood pt-13.3* ptt-31.1 inr(pt)-1.2* [**2172-7-31**] 03:00pm blood fibrino-409* [**2172-7-31**] 03:00pm blood glucose-151* urean-88* creat-4.8* na-137 k-5.0 cl-106 hco3-14* angap-22* [**2172-7-31**] 03:00pm blood alt-51* ast-71* ld(ldh)-330* ck(cpk)-1751* totbili-0.3 [**2172-7-31**] 03:00pm blood ck-mb-27* mb indx-1.5 ctropnt-0.08* [**2172-7-31**] 03:00pm blood albumin-3.0* calcium-6.9* phos-5.2* mg-1.8 iron-77 [**2172-7-31**] 03:00pm blood caltibc-127* ferritn-4249* trf-98* [**2172-8-2**] 01:27am blood cortsol-32.6* [**2172-8-1**] 04:08am blood crp-greater th [**2172-7-31**] 03:00pm blood vanco-13.7 [**2172-7-31**] 03:12pm blood lactate-2.7* [**2172-7-31**] 09:03pm blood o2 sat-98 [**2172-7-31**] 03:54pm blood freeca-1.03* labs on discharge from [**hospital1 18**] =============================== [**2172-8-20**] 06:50am blood wbc-4.9 rbc-3.14* hgb-9.0* hct-29.9* mcv-95 mch-28.8 mchc-30.2* rdw-17.8* plt ct-173 [**2172-8-19**] 07:35am blood neuts-83* bands-4 lymphs-2* monos-3 eos-6* baso-0 atyps-0 metas-2* myelos-0 [**2172-8-20**] 06:50am blood glucose-144* urean-49* creat-1.9* na-144 k-4.2 cl-105 hco3-32 angap-11 [**2172-8-19**] 03:30pm blood alt-29 ast-31 alkphos-97 totbili-0.4 [**2172-8-11**] 02:50am blood ck-mb-5 ctropnt-0.08* probnp-[**numeric identifier 52512**]* [**2172-8-20**] 06:50am blood calcium-7.3* phos-2.5* mg-1.9 [**2172-7-31**] 03:00pm blood caltibc-127* ferritn-4249* trf-98* [**2172-8-20**] 04:32am blood type-[**last name (un) **] po2-94 pco2-55* ph-7.40 caltco2-35* base xs-6 studies cxr [**7-31**] ap radiograph of the chest was reviewed with no prior studies available for comparison. cardiomegaly is present, severe. pacemaker defibrillator lead terminates in the right ventricle. the right internal jugular line tip is at the level of superior svc. lungs are essentially clear with no appreciable pleural effusion or pneumothorax. x-ray [**8-1**] impression: possible osteomyelitis at fifth metatarsophalangeal joint. echo [**8-1**] conclusions moderate to severe spontaneous echo contrast is seen in the body of the left atrium. mild spontaneous echo contrast is present in the left atrial appendage. the left atrial appendage emptying velocity is depressed (<0.2m/s). the right atrium is dilated. mild spontaneous echo contrast is seen in the body of the right atrium. a mobile echodensity is seen on the ra portion of the icd lead (best seen on clips 4, 67, and 95). no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is severely depressed (lvef= 20 %). there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no mass or vegetation is seen on the mitral valve. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate [2+] tricuspid regurgitation is seen. the pulmonary artery systolic pressure could not be determined. impression: mobile echodenisty on the icd lead may be a vegetation, but cannot be distinguished from fibrin formation. no vegetations seen on the mitral, tricuspid, or aortic valves. mild mitral regurgitation. moderate tricuspid regurgitation about the icd lead. severe global left ventricular dysfunction. cxr [**8-1**] impression: low lung volumes, no change since prior chest x-ray. cxr [**8-2**] clinical history: patient intubated for respiratory failure, evaluate position of endotracheal tube. the tip of the endotracheal tube lies 4.8 cm from the carinal angle in a satisfactory position. there has been no significant change since the prior chest x-ray. the heart remains enlarged but failure is not currently present. ct chest/abd/pelvis [**8-4**] impression: 1. no ct evidence for abscess. 2. atrophic kidneys with multiple round lesions which are incompletely evaluated on this study. further evaluation is recommended with non-urgent ultrasound. 3. cholelithiasis without evidence for cholecystitis. 4. arterial atherosclerosis including the coronary arteries as well as aortic valve calcifications of indeterminate hemodynamic significance. 5. calcified right thyroid nodule. if not done recently, further evaluation is recommended with ultrasound. 6. bilateral pleural effusions with adjacent atelectasis. 7. nasogastric tube terminating just below the gastroesophageal junction. advancing the tube is recommended. ultrasound upper extremity [**8-6**] impression: 1. nonocclusive thrombus seen within the internal jugular vein bilaterally. 2. a short segment of the left cephalic vein contains occlusive thrombus. ultrasound lower extremity [**8-6**] impression: no evidence of deep vein thrombosis in either leg. scrotal ultrasound [**8-9**] impression: no evidence of deep vein thrombosis in either leg. ct pelvis [**8-10**] impression: 1. no evidence of scrotal air. soft tissue stranding is noted along the left thigh and anterior abdominal wall subcutaneous tissues. 2. diffuse calcific atherosclerosis. 3. possible thickening of the rectal wall may be evaluated by digital rectal exam. cxr [**8-11**] findings: as compared to the previous radiograph, the pre-existing predominantly basal parenchymal opacity has slightly increased bilaterally. an infectious cause for this opacity is possible. in addition, signs of moderate pulmonary edema are present. persistent blunting of the left costophrenic sinus, caused by a small left pleural effusion. the right picc line has been removed in the interval. there is unchanged evidence of a correctly positioned left pectoral pacemaker. ct head [**8-11**] impression: 1. study limited by artifacts. 2. no acute hemorrhage. 3. large left posterior cerebral artery territory infarction, which appears to be chronic. extensive chronic small vessel ischemic disease in the supratentorial white matter. while no ct evidence of an acute major vascular territory infarction is seen, mri would be more sensitive for an acute infarction, particularly in the setting of extensive chronic changes. ultrasound uppter extremity [**8-14**] impression: 1. new left basilic partially occlusive thrombus adjacent to an existing picc. 2. unchanged non-occlusive thrombus within the left cephalic vein. 3. unchanged small non-occlusive thrombus within the left ij. pathology skin biopsy [**7-31**] specimen submitted: left abdomen procedure date tissue received report date diagnosed by [**2172-7-31**] [**2172-8-1**] [**2172-8-4**] dr. [**last name (stitle) **] [**last name (namepattern4) 12033**]/lo?????? diagnosis: skin, left abdomen: patchy vacuolar interface change, spongiosis with focal subcorneal necrosis, and superficial to mid-dermal perivascular lymphocytic infiltrate with abundant eosinophils (see note). note: no bacteria, fungi or acid fast bacilli are seen on brown-brenn, gms, [**last name (un) 18566**] and afb stains. immunostains for cmv, hsv1 and 2, and vzv are negative. no vasculitis or superficial pustulosis is seen. in the described clinical context, the findings are most suggestive of a systemic hypersensitivity reaction, as to a drug. clinical: specimen submitted: left abdomen. clinical: 76 yr. old male with sepsis and on many antibiotics for past 6 weeks with morbilliform rash. please evaluate for drug hypersensitivity, agep, dress, vasculitis, infectious, toxic erythema. gross: the specimen is received in a formalin filled container labeled with the patient's name ""[**known firstname **] [**initials (namepattern4) **] [**known lastname 52513**]"", medical record number and date of birth. specimen consists of a punch of skin measuring 4.4 cm in diameter excised to a depth of 0.8 cm. the surface of the skin is remarkable for an irregularly-shaped light pink papule measuring 0.3 x 0.3 cm. the margin is inked in blue. the specimen is bisected and entirely submitted in cassette a. brief hospital course: this is a 76 year old gentleman w/ a hitory of cardiomyopathy, af not on coumadin, recurrent nonhealing ulcers and recent osteomyelitis transferred from [**hospital3 **] with severe sepsis w/o definite source. active issues #. shock: the pt was transferred to [**hospital1 18**] micu in shock, likely due to combination -of septic and cardiogenic etiologies. he was treated empirically for sepsis with broad spectrum antibiotics including vancomycin and meropenem for 7 days. weaned off all pressors on [**8-4**]. no source of infection was identified and antibiotics were discontinued on [**8-7**]. he was afebrile and hd stable at the time of transfer to medicine floor. the etiology of his sepsis was not identified. at the time of discharge, pt had been stable off of antibiotics and was afebrile without leukocytosis. # ischemic cardiomyopathy: ef 20-30% on echo ([**8-1**]). a nstemi prior to transfer to [**hospital1 18**] cannot be ruled out given slightly elevated ckmb and troponin. lisinopril, and spironolactone were held. asa and plavix were continued. his statin was restarted. he was given iv lasix for volume overload and responded well to doses of 120 iv. he was put on metoprolol 12.5 mg [**hospital1 **]. his lisinopril and spironolactone were still on hold at the time of discharge because of unstable kidney function. on telemetry, there has been frequent asymptomatic pvc and nsvt. # [**last name (un) **]/ckd: patient developed acute renal failure and required cvvh while in the micu in the setting of hypotension and shock likely related to atn. renal was consulted, his urine sedimentation showed granular casts without muddy brown casts. he was not hyperkalemic, acidotic or uremic. at the time of transfer to medicine floor he did not need further cvvh though he was oligouric making 300cc or urine on the day prior to transfer. in the setting of low free water intake he became hypernatremic with a free water deficit. the hypernatremia and uop improved with diuresis and d5w resuscitation. his creatinine was stable around 2 at time of discharge. # respiratory failure: he was intubated for inadequate compensation for metabolic acidosis/concomitant respiratory acidosis. he was extubated on [**8-5**]. upon transfer to [**hospital1 **] he was breathing well on 3l o2. on the medical floor, he occasionally required 2l nc to maintain his o2 saturation above 90%. he had one night of desaturation into the 70s when sleeping which required transfer to the micu. this was most likely secondary to chronic air trapping with obesity hypoventilation and pulmonary edema as his lasix had been held in the setting of increased diarrhea from cdiff. his oxygenation improved with diuresis and cpap, and he was transferred back to the floor. sleep medicine evaluated the patient who recommended bipap 10/5 when sleeping. # upper extremity non-occlusive thrombi: reported history of cns bleed, according to the pcp, [**name10 (nameis) **] had a spontaneous intracranial hemorrheage. anticoagulation was held given history of spontaneous intracranial hemorrhage. upper extremity us showed multiple ij thrombi and a thrombus at the picc site. picc was d/ced, left arm swelling decreased. vascular was consulted about possible svc filter but recommended against placement at this time. he is scheduled for outpatient vascular follow up. # c. diff: patient was noted to have diarrhea on [**8-15**]. cdiff was positive. he was started on po vancomycin. he remained afebrile without leukocytosis and his diarrhea improved. he was discharged with plans to complete a 14 day course of po vancomycin (last day [**2172-8-29**]). # pusutular drug reaction: the pt developed a body rash at osh, although exact cause of the reaction was unclear. review of discharge medications from life care [**location (un) 3320**] was unrevealing as there were no new medications at the time of discharge. however, it is unclear which meds were given while he was at rehabilitation. he completed a course of clobetasol propionate 0.05% ointment with marked improvement. per dermatology, this is consistent with acute generalized exanthematous pustulosis (agep), a drug reaction, although unclear which medication at the rehab was the culprit. if recurs, will need to follow lft and eos. rash had resolved by discharge. new erythematous blanching rash on abdomen and thighs started on [**8-18**], is stable and likely from irritation. this will need to be monitored at rehab. #. atrial fibrilation with rvr: cardiology was consulted and recommended rate control with metoprolol and continued diuresis. he was maintained on telemetry. he was not anticoagulated for afib as he had hx of spontaneous intracranial bleeding. # osteomyelitis: pt has a history of unhealing ulcers secondary to pvd. amputation was suggested, but declined by the patient in the past. he developed osteomyelitis about 2 months prior to admission, and treated with 6 wk course of vanco/zosyn for right non-healing ulcer. imaging [**7-29**] at osh showed slight worsening vs prior. at [**hospital1 18**], on [**7-31**], plain film of the right foot was concerning for osteomyeltiis involving right #5 metatarsal. esr and crp on [**2172-8-8**] unremarkable. podiatry did a biopsy through the wound, cultures were negative (on antibiotics). podiatry ecommended local wound care, wet to dry dressings, off-loading multipodus boots. weight bearing status: pwbat to right heel. he will need to follow up with podiatry after discharge. # ischemic toes: the pt was noted to have necrotic toes concerning of ischemia in setting of coming off pressors. his non invasive aterial study on [**8-7**] showed monophasic dp on r and triphasic pedal pulses on l. vascular surgery was consulted and felt that observation with follow up as an outpatient was appropriate. # agitation/ams: this occured while pt was on the floor and differential included hypoglycemia vs hypernatremia vs ongoing occult infection. his nighttime insulin dose was decreased. hypernatremia was treated with d5w. respiratory distress also a factor which improved during the day with stimulation and family members. # swollen painful scrotum: concerning for fournier's gangerene, urology consulted and found no evidence of fournier's on u/s or ct. he responded to repositioning. this was likely due to edema from fluid overload. # dm: on glargine and insulin sliding scale. # communication: wife [**name (ni) **] [**telephone/fax (2) 52514**]c [**telephone/fax (2) 52515**]h # code:dnr (but icd active), okay to re-intubate transitional issues: ======================== # code status: dnr (with icd active), ok to intubate # pending studies -blood culture: [**8-10**] x2 - ngtd # medication changes - stopped aldactone - stopped atenolol - stopped allopurinol - stopped ambien - stopped hctz - stopped glyburide - changed metoprolol succinate to tartrate - started lantus and sliding scale insulin - started vancomycin po - started nystatin powder - started calcium carbonate as started - started lidocaine patch #transitional issues -thyroid ultrasound as per ct above -pt has latex allergy -diuresis as tolerated to maximize his volume status (has responded to lasix iv 120 mg boluses) -electrolyte monitoring [**hospital1 **] -strict is/os, daily weights -please remove foley -cpap -complete treatment of c.diff (last day is [**8-29**]) -monitor rash on abdomen -physical therapy -wound care site: bilateral feet wounds (r>l) description: -circular ulcer on plantar side of r 5thmtp, no signs of infection-superficial pressure ulcer on l lateral heel care: right foot: wet to dry dressing, change daily.left foot: care per pressure ulcer protocol site: sacral and coccyx skin breakdown description: there is mild maceration and there is a darker area on the left gluteal concerning for possible deep tissue injury. the pt reports pain to the area. the entire area is approx 5 x 7cm. the pt is incontinent of stool and this may be contributing to the skin breakdown - there is no perianal dermatitis or skin breakdown. the skin impairment noted above may be related to pt's drug rash and worsened by incontinence and pressure. care: cleanse skin gently after each bm using aloe vesta foam and soft disposable towelettes avoid rubbing, instead pat tissues gently to avoid increased pain apply thin layers of critic aid across entire perineal and gluteal tissues no need to reapply after each bm, reapply after 3rd cleansing only -needs cardiology follow up for heart failure management -needs vascular follow up for ischemic toes and upper extemity clot -needs sleep follow up for sleep study and management of osa -consider pfts and pulmonary follow up -needs ultrasound of renal masses seen on ct -needs ultrasound of calcified thyroid nodule seen on ct medications on admission: preadmissions medications listed are incomplete and require futher investigation. information was obtained from family/caregiver. 1. furosemide 120 mg po bid 2. glyburide 1.25 mg po daily 3. atenolol 25 mg po daily 4. aspirin 81 mg po daily 5. clopidogrel 75 mg po daily 6. lisinopril 5 mg po daily 7. pravastatin 40 mg po daily 8. albuterol inhaler 1 puff ih q6h:prn wheezing 9. zolpidem tartrate 10 mg po hs:prn insomnia 10. oxycodone-acetaminophen (5mg-325mg) 1 tab po frequency is unknown 11. acetaminophen 650 mg po frequency is unknown 12. allopurinol 300 mg po daily 13. amoxicillin dose is unknown po frequency is unknown as needed for flu symptoms 14. ascorbic acid 1000 mg po daily 15. guaifenesin *nf* 600 mg oral [**hospital1 **]: prn 16. spironolactone 25 mg po daily:prn blood pressure 17. hydrochlorothiazide 25 mg po daily:prn blood pressure 18. metoprolol succinate xl 25 mg po daily preadmissions medications listed are incomplete and require futher investigation. information was obtained from family/caregiver. 1. furosemide 120 mg po bid 2. glyburide 1.25 mg po daily 3. atenolol 25 mg po daily 4. aspirin 81 mg po daily 5. clopidogrel 75 mg po daily 6. lisinopril 5 mg po daily 7. pravastatin 40 mg po daily 8. albuterol inhaler 1 puff ih q6h:prn wheezing 9. zolpidem tartrate 10 mg po hs:prn insomnia 10. oxycodone-acetaminophen (5mg-325mg) 1 tab po frequency is unknown 11. acetaminophen 650 mg po frequency is unknown 12. allopurinol 300 mg po daily 13. amoxicillin dose is unknown po frequency is unknown as needed for flu symptoms 14. ascorbic acid 1000 mg po daily 15. guaifenesin *nf* 600 mg oral [**hospital1 **]: prn 16. spironolactone 25 mg po daily:prn blood pressure 17. hydrochlorothiazide 25 mg po daily:prn blood pressure 18. metoprolol succinate xl 25 mg po daily discharge medications: 1. collagenase ointment 1 appl tp daily please apply to ulcers with dressing changes. 2. docusate sodium (liquid) 100 mg po bid:prn constipation 3. glargine 16 units bedtime insulin sc sliding scale using novolog insulin 4. aspirin 81 mg po daily 5. clopidogrel 75 mg po daily 6. heparin 5000 unit sc tid 7. miconazole powder 2% 1 appl tp qid:prn fungal areas 8. senna 1 tab po bid 9. albuterol inhaler 1 puff ih q6h:prn wheezing 10. ascorbic acid 1000 mg po daily 11. acetaminophen 650 mg po q6h:prn pain 12. pravastatin 40 mg po daily 13. calcium carbonate 1000 mg po qid:prn heartburn 14. vancomycin oral liquid 125 mg po q6h started [**8-16**] 15. sodium chloride nasal [**12-16**] spry nu qid:prn dry nasopharynx 16. lidocaine 5% patch 1 ptch td daily apply lower back/sacrum near area of pain 17. dextrose 50% 12.5 gm iv prn hypoglycemia protocol 18. metoprolol tartrate 12.5 mg po bid hold for sbp<100 hr<60 19. furosemide 120 mg iv bid:prn volume overload 20. glucagon 1 mg im q15min:prn hypoglycemia protocol discharge disposition: extended care facility: [**hospital1 700**] - [**location (un) 701**] discharge diagnosis: primary diagnosis - sepsis - congestive heart failure (systolic, acute on chronic, ef 20-30%) - nonhealing foot ulcer secondary diagnosis - diabetes mellitus - atrial fibrillation - chronic kidney disease - drug rash discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: dear mr. [**known lastname 52513**], it was a pleasure taking care of you at the [**hospital1 771**]. you were transferred from an outside hosiptal with sepsis, which is a serious illness that happens when an infection affects the whole body so your heart had trouble to supply your organs. after aggressive medical management including strong antibiotics, blood pressure medications, respiratory support, cardiovascular support, you were able to recover from the serious illness. the source of your infection was not identified despite our best effort in multiple radiology scans, and labs tests. however, due to your serious condition, a number of your organs have been affected. your kidney was damaged for lack of blood supply. fortunately, it has improved and you did not require dialysis. your toes turned blue because of lack of blood supply. secondly, you came in with a diffuse body rash that we thought was caused by a drug reaction. the drug that might have caused your rash was never identified. your rash improved with a steroid cream. also, in the search of your infection source we found multiple clots in your upper arms where the iv lines previously were placed. you did not have occlusion of your arm vessels. we did not give you blood thinning medications given your adverse reaction to coumadin in the past. you also had an infection of your bowel with a bacteria called clostridium difficile which causes diarrhea. it was treated with oral vancomycin which you will continue until [**2172-8-29**]. you also had trouble breathing which required a transfer to the medical icu for one night. you were placed on cpap breathing machine and given more lasix which improved your symptoms and you were able to come back to the medical floor. you also received intravenous medication to remove fluids from your body. we were able to make some progress. however it appears that this process will take some time. we think that you may benefit from further diuresis in a rehab setting, where more targeted nursing and physical therapy could also be provided. please note that a number of changes have been made to your medications. please follow up with your providers as scheduled. you will need to be seen by cardiology and vascular surgery providers. you should also follow up in the sleep clinic to help manage your sleep apnea. followup instructions: department: vascular surgery when: tuesday [**2172-9-1**] at 10:30 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 we are working on a follow up appointment for your hospitalization in pulmonary sleep medicine. it is recommended you be seen within 1 month of discharge. the office will contact you with the appointment information. if you have not heard within a few business days please call the office at [**telephone/fax (1) 612**]. department: cardiac services when: tuesday [**2172-9-1**] at 2:00 pm with: [**name6 (md) **] [**last name (namepattern4) 6738**], md [**telephone/fax (1) 62**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) **] campus: east best parking: [**hospital ward name 23**] garage completed by:[**2172-8-23**]",1
6,"admission date: [**2198-11-28**] discharge date: [**2198-12-31**] date of birth: [**2145-9-4**] sex: f service: surgery allergies: no known allergies / adverse drug reactions attending:[**first name3 (lf) 6088**] chief complaint: poor wound healing, left lower extremity ischemia major surgical or invasive procedure: [**2198-12-6**]: 1. bilateral groin cutdowns. 2. left-to-right femoral-femoral artery bypass graft placement. 3. left femoral artery-to-above-knee popliteal artery bypass graft with non-reversed saphenous vein graft. [**date range (3) 88240**]: 1. exploration of left-to-right femoral-femoral artery bypass graft and left femoral-to-above-knee popliteal artery bypass graft. 2. [**doctor last name **] thrombectomy of femoral artery-to-femoral artery bypass graft and left femoral artery-to-above-knee popliteal artery bypass graft and [**doctor last name **] embolectomy of left aortofemoral bypass graft. 3. bovine patch angioplasty of proximal anastomosis of left femoral-to-above-knee popliteal artery bypass graft and vein patch repair of femoral-popliteal bypass. 4. aortogram. 5. selective catheterization of the femoral artery-to- femoral artery bypass graft and of the left femoral-to- above-knee popliteal bypass graft. 6. serial arteriogram of the left lower extremity. [**2198-12-20**]: left groin irrigation and debridement with sartorius muscle flap coverage of the vascular anastomosis and vacuum assisted dressing closure. history of present illness: 53 y/o f pmhx iddm, extensive vascular disease, and poor wound healing was a transfer from [**state **] center with concern for b/l foot osteomyelitis. she has a prior history of a chronic l foot ulcer s/p i&[**initials (namepattern4) **] [**last name (namepattern4) **] [**2197**] post with 6 week course of linezolide; r 2nd toe amputation [**2198-10-29**] for wet gangrene. 4 days prior to admission, vna noted increased erythema surrounding l foot ulcer after the pt wore wet shoes the day prior. denies any addition s/sx including: discharge, f/c, cough, sob/cp, n/v/d, abd pain, n/t/w (decreased b/l foot sensation at baseline), ha, or pain located over l or r foot ulcers, gi/gu frequency. continues to ambulate with cane. no exacerbating or relieving factors. identical to prior wound infections. . whilst at [**hospital **] hospital, pt started on vanco, evaluated by dr. [**last name (stitle) **], and had mri that showed questionable osteomyelitis; vanco changed to daptomycin for unclear reason upon chart review or questioning pt; no noted adverse reactions to vancomycin. pt transfer to [**hospital1 18**] for podiatry and vascular eval. in addition, inr noted to be > 3 and coumadin was held on admission. past medical history: type 2 diabetes mellitus copd/asthma atrial fibrillation chronic on coumadin hyperlipidemia mdd chronic anemia osteomyelitis - l foot s/p i&[**initials (namepattern4) **] [**2198-5-22**] peripheral vascular disease s/p amputation of r 2nd toe [**2198-10-29**] [**1-23**]; l abi 0.79, r 0.45 mediastinal adenopathy charcot feet deformity social history: disabled, history of remote tobacco use (20pyh). denies drug, and alcohol use lives with grandson; able to do adl's independently family history: brother, sister, father with dm physical exam: vs: t 97.7 bp 142/82 hr 50 sao2 98%ra general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: regular rate and rhythm, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, dopplerable dp pulses b/l skin: l foot: 1cmx4cm linear stage 3 ulcer along arch with marked area of erythema, no discharge, 1cm round stage 2 ulcer over 1st metatarsal; r foot: 2nd toe amputated with 1cm round stage 2 ulcer, and 1st metatarsal with 1cm round stage 2 ulcer; l groin with wound vac pulses: dopplerable dp/pt bilat neuro: cn 2-12 grossly intact; sensation below motor: 5/5 strength through ue/le bil sensation: decreased 2pt and proprioception at toes bil dtr: wnl pertinent results: [**2198-12-24**] 06:47am blood wbc-10.5 rbc-3.64* hgb-10.1* hct-30.6* mcv-84 mch-27.7 mchc-32.9 rdw-16.7* plt ct-587* [**2198-12-25**] 05:08am blood wbc-9.2 rbc-3.46* hgb-10.0* hct-29.0* mcv-84 mch-28.8 mchc-34.3 rdw-16.5* plt ct-596* [**2198-12-26**] 05:20am blood wbc-8.9 rbc-3.50* hgb-9.7* hct-29.5* mcv-84 mch-27.8 mchc-33.0 rdw-15.7* plt ct-565* [**2198-12-25**] 05:08am blood pt-21.2* ptt-28.9 inr(pt)-2.0* [**2198-12-26**] 05:20am blood pt-23.3* ptt-28.4 inr(pt)-2.2* [**2198-12-27**] 05:32am blood pt-24.1* inr(pt)-2.3* [**2198-12-28**] 06:02am blood pt-21.7* inr(pt)-2.0* [**2198-12-20**] 11:39am blood glucose-154* urean-28* creat-1.0 na-133 k-3.8 cl-97 hco3-29 angap-11 [**2198-12-21**] 05:00am blood glucose-55* urean-28* creat-1.1 na-133 k-3.9 cl-97 hco3-31 angap-9 [**2198-12-22**] 05:24am blood glucose-110* urean-32* creat-1.3* na-131* k-4.2 cl-96 hco3-30 angap-9 [**2198-12-23**] 05:36am blood glucose-148* urean-34* creat-1.3* na-132* k-3.8 cl-93* hco3-32 angap-11 [**2198-12-24**] 06:47am blood glucose-106* urean-33* creat-1.2* na-130* k-3.9 cl-95* hco3-29 angap-10 [**2198-12-25**] 05:08am blood glucose-138* urean-32* creat-1.1 na-133 k-3.8 cl-97 hco3-28 angap-12 [**2198-12-26**] 05:20am blood glucose-106* urean-31* creat-1.1 na-136 k-4.3 cl-101 hco3-31 angap-8 [**2198-12-24**] 06:47am blood calcium-9.0 phos-3.9 mg-2.0 [**2198-12-25**] 05:08am blood calcium-8.4 phos-3.1 mg-1.8 [**2198-12-26**] 05:20am blood calcium-9.1 phos-3.1 mg-1.9 [**2198-12-5**] 06:35am blood %hba1c-11.0* eag-269* [**2198-12-5**] 06:35am blood triglyc-95 hdl-44 chol/hd-2.4 ldlcalc-42 [**2198-12-3**] 09:39am blood tsh-0.090* [**2198-12-7**] 01:10pm blood tsh-0.16* [**2198-12-10**] 04:11am blood tsh-0.20* [**2198-12-12**] 04:45am blood tsh-0.14* [**2198-12-17**] 05:56am blood tsh-0.074* [**2198-12-24**] 06:47am blood tsh-0.088* [**2198-12-28**] 06:02am blood tsh-pnd [**2198-12-4**] 06:45am blood t4-6.5 t3-98 calctbg-0.86 tuptake-1.16 t4index-7.5 free t4-1.2 [**2198-12-7**] 01:10pm blood t4-5.2 t3-91 calctbg-0.88 tuptake-1.14 t4index-5.9 [**2198-12-10**] 04:11am blood t4-5.8 t3-76* calctbg-0.82 tuptake-1.22 t4index-7.1 [**2198-12-24**] 06:47am blood t4-10.2 t3-117 calctbg-0.82 tuptake-1.22 t4index-12.4* [**2198-12-24**] 06:47am blood crp-67.2* [**2198-12-20**] 10:00 am swab left groin. **final report [**2198-12-27**]** gram stain (final [**2198-12-20**]): no polymorphonuclear leukocytes seen. no microorganisms seen. wound culture (final [**2198-12-27**]): due to mixed bacterial types (>=3) an abbreviated workup is performed; p.aeruginosa, s.aureus and beta strep. are reported if present. susceptibility will be performed on p.aeruginosa and s.aureus if sparse growth or greater.. dr. [**last name (stitle) 10000**] requested further work-up [**2198-12-25**]. pseudomonas aeruginosa. sparse growth. escherichia coli. sparse growth. piperacillin/tazobactam sensitivity testing available on request. escherichia coli. rare growth. 2nd morphology. piperacillin/tazobactam sensitivity testing available on request. escherichia coli. rare growth. 3rd morphology. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | escherichia coli | | escherichia coli | | | escherichia coli | | | | amikacin-------------- 16 s ampicillin------------ =>32 r =>32 r =>32 r ampicillin/sulbactam-- =>32 r 16 i 16 i cefazolin------------- 8 s <=4 s <=4 s cefepime-------------- 8 s <=1 s <=1 s <=1 s ceftazidime----------- 4 s <=1 s <=1 s <=1 s ceftriaxone----------- <=1 s <=1 s <=1 s ciprofloxacin--------- =>4 r =>4 r =>4 r =>4 r gentamicin------------ =>16 r <=1 s <=1 s <=1 s meropenem------------- 8 i <=0.25 s <=0.25 s <=0.25 s piperacillin/tazo----- 16 s tobramycin------------ =>16 r <=1 s <=1 s <=1 s trimethoprim/sulfa---- =>16 r =>16 r =>16 r anaerobic culture (final [**2198-12-24**]): no anaerobes isolated. [**2198-12-11**] 5:22 am blood culture source: line-cvl. **final report [**2198-12-17**]** blood culture, routine (final [**2198-12-17**]): no growth. [**2198-12-8**] 3:41 pm swab source: rectal swab. **final report [**2198-12-11**]** r/o vancomycin resistant enterococcus (final [**2198-12-11**]): no vre isolated [**2198-12-3**] 7:58 am swab source: left foot. **final report [**2198-12-13**]** gram stain (final [**2198-12-3**]): no polymorphonuclear leukocytes seen. no microorganisms seen. wound culture (final [**2198-12-12**]): beta streptococcus group b. sparse growth. susceptibility testing requested by dr. [**last name (stitle) 59051**] #[**numeric identifier 88241**] [**2198-12-10**]. sensitivity testing performed by sensititre. this isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . staphylococcus, coagulase negative. rare growth. susceptibility testing requested by dr. [**last name (stitle) 59051**] #[**numeric identifier 88241**] [**2198-12-10**]. coag neg staph does not require contact precautions, regardless of resistance oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. sensitivities: mic expressed in mcg/ml _________________________________________________________ beta streptococcus group b | staphylococcus, coagulase negative | | clindamycin----------- r <=0.25 s erythromycin---------- =>4 r <=0.25 s gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r penicillin g----------<=0.06 s rifampin-------------- <=0.5 s tetracycline---------- <=1 s vancomycin------------ <=1 s <=0.5 s anaerobic culture (final [**2198-12-7**]): no anaerobes isolated. discharge labs: 140 105 31 50 agap=11 ------------- 4.4 28 0.8 estgfr: 75 / >75 (click for details) ca: 9.0 mg: 1.7 p: 3.6 pt: 18.6 ptt: 25.7 inr: 1.7 brief hospital course: 53yo f pmhx iddm, extensive vascular disease, and poor wound healing presenting with s/sx concerning for osteomyelitis and cellulitis of l foot ulcers. she was admitted to the medicine service for management of her osteomyelitis, foot ulcers, and multiple comorbidities, and was followed by podiatry bilateral charcot deformities. vascular surgery was consulted for concern for inadequate vascularization and further work-up revealed occlusion of her previous aorto-bifem graft. at that point, she was transferred to the vascular surgery service for further management. she was taken to the or for left-to-right fem-fem bypass and left femoral to above-knee popliteal artery bypass. this was complicated by graft thrombosis requiring take-back to the or the same night for thrombectomy. she required massive fluid resuscitation during the perioperative period, which caused respiratory and cardiac difficulties. neuro: her pain was well-controlled with oral and iv pain medications. she was intubated briefly in the post-operative period, sedated on fentanyl and versed, but responded appropriately when sedation was lightened. after extubation, she awoke and was alert and oriented, without neurologic deficits and no neurologic issues for the rest of her hospitalization. cv: she has chronic atrial fibrillation, which was well-controlled on her home medications until her massive fluid resuscitation. at that time, she went into afib with rvr, which required esmolol and diltiazem drips while in the icu for heart rate control. once her volume status improved, she was re-started on her home medications with good rate control and had no further issues during the course of her hospitalization. pulm: she has copd at baseline, which is well-controlled with inhalers. she was intubated for the or and could not be extubated until pod 3 due to her volume status. she had acute pulmonary edema and was heavily diuresed with lasix. once extubated she required intermittent bipap for a few days, and was then weaned to nasal cannula. her oxygen requirements continued to decrease as her volume status improved, until she was not requiring supplemental oxygen for the majority of her hospitalization. fen/gi: she required massive fluid resuscitation in the perioperative period, and was nearly 20 liters positive post-operatively. once her atrial fibrillation was controlled and her blood pressure stable, she was gently diuresed with a lasix drip. her electrolytes were monitored and repleted appropriately, and her kidney function remained stable. she received tube feeds for several days post-op, and began eating her regular diet once extubated. nutrition was consulted and provided recommendations to optimize intake to improve wound healing. dr. [**first name (stitle) 3209**] from podiatry recommended midfoot/forefoot reconstruction at a further date as an oupatient for charcot's foot. she should call the [**hospital1 18**] podiatric surgery clinic for further follow-up of this condition at ([**telephone/fax (1) 21608**]. gu: her kidney function was monitored regularily and remained stable. heme/id: she was admitted for management of left foot ulceration, cellulitis, and osteomyelitis. her x-rays on admission were concerning for osteomyelitis, and wound cultures grew group b strep and mrse. she was treated with vanco/cipro/flagyl. she was kept on a heparin drip for a-fib perioperatively, and then transitioned back to coumadin. picc was placed on [**12-18**] for long term abx and temporary central line removed. she was given 1 unit of rbcs on [**12-20**] for hct of 28, post transfusion hct showed no response. wound cultures from the or on [**12-20**] grew out multi drug resistant pseudomonas aeruginosa and 3 morphologies of e.coli. infectious disease was consulted and recommended cefepime 2 gm [**hospital1 **] and metronidazole 500 mg po tid. with duration of therapy 6 weeks following last debridement. she should have weekly cbc/diff, bun/cr, and lft's while on the above therapy; please have labs faxed per the opat note to id rn's at [**telephone/fax (1) 1419**]. endo: she has poorly controlled type 2 diabetes. we consulted endocrinology for recommendations for blood sugar control while admitted. a pre-op chest x-ray also revealed a large substernal thyroid mass causing tracheal deviation. endocrinology also evaluated her for this process and recommended outpatient biopsy with likely removal by thoracic surgery. she was continued on methimazole and tfts monitored throughout her hospitalization. endocrinology has recommended that she follow up with her outpatient endocrinologists in [**1-25**] weeks after discharge with a repeat of her thyroid function tests (tfts). left lower extremity wounds: she had left groin wound dehiscence and large amounts of serous drainage postoperatively. on [**12-20**], she was taken to the operating room for left groin wound debridement, sartorius flap, and vac placement. her vac was changed every three days while in the hospital. her left and right foot ulcers were debrided and treated with santyl ointment which should continue at discharge. at the time of discharge she was stable. her inr was 1.7 and she was continued on coumadin 5mg qhs. the vac was removed from her left groin wound and it was packed with wet to dry dressing. the vac should be replaced at the rehab facility. she will continue antibioitcs as indicated and follow up with the [**hospital **] clinic, the podiatry clinic and the vascular surgery clinic. medications on admission: omeprazole 40mg po daily imdur 30mg po qday hydralazine 10 po tid metoprolol 100mg po bid lipitor 20mg po qday lexapro 10mg po qday combivent 2 puffs qid prn ventolin hfa 2 puffs q4hrs prn mvit qday ferrous sulfate 325mg po qday coumadin 5mg qday lantus 80u subq daily humalog ss cardizem 240mg po qday discharge medications: 1. ceftazidime 2 gram recon soln sig: two (2) grams injection q8h (every 8 hours) for 6 weeks: start date [**2198-12-24**] for 6 weeks. stop date [**2199-2-4**]. disp:*qs * refills:*0* 2. heparin, porcine (pf) 10 unit/ml syringe sig: 2 ml mls intravenous prn (as needed) as needed for line flush: picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. . 3. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours): start date [**2198-12-24**] cont for 6 weeks stop date [**2199-2-4**]. 4. collagenase clostridium hist. 250 unit/g ointment sig: one (1) appl topical daily (daily). 5. bisacodyl 10 mg suppository sig: one (1) suppository rectal [**hospital1 **] (2 times a day) as needed for constipation. 6. diltiazem hcl 120 mg capsule, sustained release sig: two (2) capsule, sustained release po daily (daily). 7. escitalopram 10 mg tablet sig: one (1) tablet po daily (daily). 8. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day). 9. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 10. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 11. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 12. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for dyspnea. 13. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 14. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 15. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: [**12-23**] puffs inhalation q6h (every 6 hours) as needed for sob, wheeze. 16. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation q4h (every 4 hours) as needed for sob, wheeze. 17. methimazole 10 mg tablet sig: three (3) tablet po daily (daily). 18. morphine 5 mg/ml solution sig: 2 mg iv injection before vac removal/placement (). 19. insulin glargine 100 unit/ml solution sig: 52 units subcutaneous at breakfast. 20. insulin sliding scale-humalog insulin sc sliding scale breakfast lunch dinner bedtime 71-119 10units 6units 9units 0units 120-140 12units 8units 11units 0units 141-199 14units 10units 13units 2units 200-239 16units 12units 15units 4units 240-280 18units 14units 17units 6units > 280 notify md 21. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm: please check inr twice per week; inr goal 2.0-3.0. 22. outpatient [**name (ni) **] work pt/inr labs twice weekly; please adjust coumadin dose as needed. inr goal 2.0-3.0 weekly cbc/diff, bun/cr, and lft's while on the antibiotics; please have labs faxed id rn's at [**telephone/fax (1) 1419**]. discharge disposition: extended care facility: [**hospital1 2670**] - the elms [**first name5 (namepattern1) 5871**] [**last name (namepattern1) **] discharge diagnosis: left lower extremity ischemia left groin lymphatic leak with wound dehiscence discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted for a lower extremity bypass operation that included establishing blood flow from your left femoral to right femoral artery and from your left femoral to left popliteal artery followed by an operation to protect your graft after lymphatic leak. you were also being treated with iv antibiotics to treat infection in the wounds. what to expect when you go home: 1. it is normal to feel tired, this will last for 4-6 weeks ?????? you should get up out of bed every day and gradually increase your activity each day ?????? unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? increase your activities as you can tolerate- do not do too much right away! 2. it is normal to have swelling of the leg you were operated on: ?????? elevate your leg above the level of your heart (use [**1-24**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? avoid prolonged periods of standing or sitting without your legs elevated 3. it is normal to have a decreased appetite, your appetite will return with time ?????? you will probably lose your taste for food and lose some weight ?????? eat small frequent meals ?????? it is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? to avoid constipation: eat a high fiber diet and use stool softener while taking pain medication what activities you can and cannot do: ?????? no driving until post-op visit and you are no longer taking pain medications ?????? unless you were told not to bear any weight on operative foot: ?????? you should get up every day, get dressed and walk ?????? you should gradually increase your activity ?????? you may up and down stairs, go outside and/or ride in a car ?????? increase your activities as you can tolerate- do not do too much right away! ?????? no heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? you may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? take all the medications you were taking before surgery, unless otherwise directed ?????? take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? call and schedule an appointment to be seen in 2 weeks for staple/suture removal what to report to office: ?????? redness that extends away from your incision ?????? a sudden increase in pain that is not controlled with pain medication ?????? a sudden change in the ability to move or use your leg or the ability to feel your leg ?????? temperature greater than 100.5f for 24 hours ?????? bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions open wound: vac dressing patient's discharge instructions introduction: this will provide helpful information in caring for your wound. if you have any questions or concerns please talk with your doctor or nurse. you have an open wound, as opposed to a closed (sutured or stapled) wound. the skin over the wound is left open so the deep tissues may heal before the skin is allowed to heal. premature closure or healing of the skin can result in infection. your wound was left open to allow new tissue growth within the wound itself. the wound is covered with a vac dressing. this will be changed around every three days. the vac helps keep the wound tissue clean, absorbs drainage, prevents premature healing of skin, and promotes appropriate healing. when to call the doctor: watch for the following signs and symptoms and notify your doctor if these occur: temperature over 101.5 f or chills foul-smelling drainage or fluid from the wound increased redness or swelling of the wound or skin around it increasing tenderness or pain in or around the wound followup instructions: your vascular surgery followup appointment: provider: [**name10 (nameis) 251**] [**last name (namepattern4) 1490**], md phone:[**telephone/fax (1) 1237**] date/time:[**2199-1-9**] 2:45 your infectious disease followup appointment: provider: [**name10 (nameis) **],[**name11 (nameis) **] [**name12 (nameis) **] id west (sb) phone:[**telephone/fax (1) 457**] date/time:[**2199-1-14**] 10:50 provider: [**first name8 (namepattern2) **] [**last name (namepattern1) 10000**], md phone:[**telephone/fax (1) 457**] date/time:[**2199-2-7**] 10:30 call podiatry for f/u completed by:[**2198-12-31**]",0
7,"admission date: [**2167-4-28**] discharge date: [**2167-7-2**] date of birth: [**2114-1-22**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**first name3 (lf) 2181**] chief complaint: transferred from osh with hypoxic respiratory failure major surgical or invasive procedure: intubation tunneled hd line placement hemodialysis picc placement, picc removal history of present illness: this is a 53 year-old woman with history of cad, chf, copd on home oxygen, pulm hypertension, polysubstance abuse who presented to osh earlier today ([**4-28**]) with altered mental status. as per records, patient presented after her vna noted medical non-compliance and apparent overuse of sedating medications and summoned ems. when patient arrived at osh, the patient was somewhat confused and hypoxic to high 80's on 3 liters. (unclear baseline requirement but on home oxygen). also tachycardic to 100, tachypneic to mid 20's and hypertensive to 160's. she had low grade fevers to 99. she was felt to be in congestive heart failure, was noted to have hyperkalemia, and apparently new renal failure with creatinine in 6's. a central line was placed but then the patient became agitated, self-extracted the femoral line. serial haldol, benadryl and ativan x3 were not effective in sedating her and therefore the patient was intubated for airway protection. the femoral line was replaced. the patient had a ng tube placed, was given kayxelate, calcium gluconate, bicarb, insulin, and glucose for hyperkalemia, las well as lasix for chf. she was given a dose of levoquin for uti/possible pneumonia. the patient had an anion gap acidosis and there was concern for ethylene glycol because ""urate crystals"" were noted in the urine. . she was noted to have coffee grounds by ngt. . the patient was transferred to [**hospital1 18**] er. in our er, received a tox consult, renal consult, gi consult and cxr. the cxr confirmed chf. flomipazole was given for possible ethylene glycol intoxication. renal recommended: no dialysis, give bicarb. gi recommended: protonix, ffp and vitamin k. tox: no other reccs. . vitamin k 10 subcut, 2 units ffp, protonix, insulin, dextrose, calcium gluconate, kaexelate and bicarb given. . past medical history: (per osh records) 1. copd-on 4l o2 by nc at home 2. pulmonary hypertension 3. cad 4. chf--diastolic dysfunction 5. anxiety 6. polysubstance abuse 7. pvd s/p l aka social history: lives alone in [**doctor last name **], has a visiting nurse. family history: unknown physical exam: admission exam vs: temp: 97.5 bp:154/65 hr:89 rr:24 100%o2sat vent: ac 550x24, fio2 of 1, peep of 10. i/o: 150/400 in our emergency department general: intubated, sedated heent: pupils equal, minimally responsive, anicteric, mmm, op without lesions, no supraclavicular or cervical lymphadenopathy lungs: crackles [**12-9**] way up heart: rr, s1 and s2 wnl, no murmurs, rubs or gallops appreciated but difficult to appreciate abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly extremities: no cyanosis, clubbing or edema. left aka skin/nails: no rashes/no jaundice/ neuro: intubated, sedated pertinent results: [**2167-4-28**] 08:30pm blood -wbc-19.5* rbc-4.94 hgb-13.1 hct-41.0 mcv-83 mch-26.5* mchc-31.9 rdw-18.5* neuts-83.7* bands-0 lymphs-10.3* monos-5.7 eos-0.2 basos-0.1 pt-28.5* ptt-30.6 inr(pt)-3.0* plt smr-high plt count-449*; hypochrom-1+ anisocyt-2+ poikilocy-normal macrocyt-normal microcyt-normal polychrom-1+ -asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-pos osmolal-313* ctropnt-0.08* ck(cpk)-231* glucose-101 urea n-105* creat-6.5* sodium-130* potassium-6.8* chloride-98 total co2-16* anion gap-23* [**2167-4-28**] 08:39pm glucose-92 lactate-1.3 k+-6.3* . [**2167-4-28**] 09:00pm urine eos-negative; rbc-[**5-17**]* wbc-21-50* bacteria-many yeast-none epi-[**5-17**]; blood-mod nitrite-neg protein-30 glucose-neg ketone-tr bilirubin-sm urobilngn-neg ph-5.0 leuk-sm; color-yellow appear-hazy sp [**last name (un) 155**]-1.020 [**2167-4-28**] 09:00pm urine bnzodzpn-neg barbitrt-neg opiates-pos cocaine-neg amphetmn-neg mthdone-neg; osmolal-376 [**2167-4-28**] 09:35pm type-art po2-60* pco2-45 ph-7.23* total co2-20* base xs--8 [**2167-4-28**] 10:55pm urea n-109* creat-6.5* sodium-135 potassium-6.2* chloride-102 total co2-17* anion gap-22* . [**2167-5-30**] wbc-9.3 hgb-11.0* hct-34.3* mcv-86 mch-27.6 mchc-32.0 rdw-23.8* plt ct-314 [**2167-6-10**] wbc-13.1* hgb-9.3* hct-30.1* mcv-93 mch-28.5 mchc-30.8* rdw-24.0* plt ct-425 [**2167-6-23**] wbc-19.0* hgb-10.7* hct-34.2* mcv-91 mch-28.2 mchc-31.1 rdw-22.1* plt ct-640* [**2167-6-24**] wbc-18.0*hgb-10.7* hct-32.8* mcv-87 mch-28.5 mchc-32.6 rdw-21.6* plt ct-578* [**2167-6-27**] wbc-16.7* hgb-11.0* hct-35.7* mcv-91 mch-28.2 mchc-30.9* rdw-21.2* plt ct-482* [**2167-6-28**] wbc-19.0* hgb-11.4* hct-36.3 mcv-91 mch-28.5 mchc-31.4 rdw-20.9* plt ct-503* . micro: -urine cultures ([**4-28**], [**5-1**], [**5-6**]): no growth. . -sputum ([**4-29**]): 3+ gram positive cocci in pairs and clusters. -sputum ([**5-1**]): 1+ yeast. . -blood ([**4-30**], [**5-1**], [**5-6**], [**5-15**], [**5-18**], [**6-22**]): negative. -blood ([**6-24**], off antibx): no growth to date. -blood ([**5-14**]): one bottle with staph coagulase negative. . -catheter tip ([**5-6**]): no growth. -catheter tip ([**5-13**]): no growth. -catheter tip ([**5-22**], [**5-26**], [**6-20**]): no growth. . -hemodialysis catheter blood cx ([**6-18**]): no growth. . -stool ([**5-8**], [**5-10**], [**5-11**], [**5-31**], [**6-27**]): c. diff. negative. . -blood ([**5-22**]): rpr negative. . [**4-30**] echo the left atrium is normal in size. the right atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. . [**5-1**] ct torso impression: 1. no bowel obstruction is identified. small bowel and large bowel loops appear unremarkable. 2. bilateral increased interstitial markings and septal thickening is suggestive of presence of the heart failure. the heart is also mildly enlarged. 3. small bilateral pleural effusions and dependent atelectatic changes are noted at both lung bases. infiltrate/infection cannot be ruled out. small pericardial effusion is also noted. 4. a 4-mm nodule is noted within the anterior portion of the right middle lobe. pathologically enlarged right paratracheal node measures 13 mm in the short axis. 5. diverticulosis with no evidence of diverticulitis. 6. the aorta demonstrates severe stenosis below the renal arteries. no aneurysmal dilatation is noted. 7. small right kidney with normal sized left kidney. no hydronephrosis or stones are identified. . [**5-1**] ct head 1. no acute intracranial abnormality. 2. chronic infarcts in the right cerebellum and centrum semiovale. 3. sinus disease involving left maxillary and sphenoid sinuses. . [**5-2**] eeg impression: this is an abnormal eeg due to the presence of probable periodic lateralizing epileptiform discharges (i.e., pleds) involving the right hemisphere which could indicate a subcortical abnormality involving this area. the presence of a diffusely slow background and disorganized background is consistent with a mild to moderate encephalopathy of toxic, anoxic, or metabolic etiology. the occasional sharp waves can be a sign of cortical irritability, but clinical correlation would need to be provided. no evidence for ongoing seizures is seen. . [**5-19**] echo/bubble study: focused study to assess for patent foramen ovale. images were obtained at rest, with cough and post-valsalva release with injection of agitated saline. no evidence for an atrial septal defect or patent foramen ovale was identified. there is symmetric left ventricular hypertrophy with preserved global systolic function. no pericardial effusion is seen. . [**5-25**] mr spine: 1. multilevel degenerative changes of the lower lumbar spine, most pronounced at the l4-5 and the l5-s1 levels respectively.2. type [**first name9 (namepattern2) **] [**last name (un) 13425**] changes of the l4 and l5 vertebral bodies respectively. 3. no evidence of epidural abscess. . [**6-10**] chest cta:1. no definite evidence of pulmonary embolus. 2. cardiomegaly, pleural effusions, and pulmonary edema, all consistent with congestive heart failure.3. right upper and right middle lobe pulmonary nodules, little change since [**2167-5-1**]. six-month followup chest ct is recommended to assess stability.4. mediastinal lymphadenopathy, likely reactive. . [**6-15**] echo bubble: saline contrast study performed to assess for intracardiac shunt. no passage of agitated saline is seen into the left heart is identified. the left ventricular cavity is normal in size. there appears to be global hypokinesis that is more pronounced/worse that the study of [**2167-5-19**]. . [**6-19**] echo: the left atrium is elongated. the right atrium is moderately dilated. the estimated right atrial pressure is [**4-16**] mmhg. left ventricular wall thicknesses and cavity size are normal. there is moderate to severe global left ventricular hypokinesis (lvef = 30 %). systolic function of apical segments is relatively preserved. no masses or thrombi are seen in the left ventricle. the right ventricular cavity is moderately dilated with mild globalfree wall hypokinesis. the aortic valve leaflets are mildly thickened. mild to moderate ([**12-9**]+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of [**2167-4-30**], global left ventricular systolic function is more depressed and the right ventricular cavity is mildly dilated and hypokinetic. the estimated pulmonary artery systolic pressure is higher. . [**6-22**] ct of the chest without iv contrast: there is no axillary lymphadenopathy. there is pretracheal lymphadenopathy measuring up to 1.5 cm. this is unchanged. there are small bilateral effusions. these are stable. again noted is an ovoid nodule in the apex of the right lung measuring 1.2 x 0.5 cm. this is stable in appearance. there are tiny nodules in the right lung. these are again stable. there is diffuse septal thickening which is unchanged. in the presence of cardiomegaly this is consistent with chf. ct of the abdomen without iv contrast: the liver is without focal lesions. the gallbladder has been removed. spleen, pancreas, adrenal glands are unremarkable. the right kidney is atrophic. the left kidney has some bulging of the contour at mid pole measuring about 1.6 cm. this is difficult to evaluate on the prior study as there is significant artifact from the patient's body touching the gantry but is likely present. there is no retroperitoneal lymphadenopathy. small and large bowel are normal. ct of the pelvis without iv contrast: the uterus is normal in size and contains some calcified fibroids. there is diverticulosis of the sigmoid colon. there is no adjacent inflammatory fat stranding. there is no free fluid in the pelvis. no pelvic adenopathy is noted. on bone windows, there are degenerative changes involving the lumbar spine. impression: 1. no findings to explain the patient's symptoms. the examination is essentially unchanged in comparison to prior studies. 2. interstitial prominence and small bilateral pleural effusions with cardiomegaly are consistent with chf. again this is stable. 3. mediastinal adenopathy unchanged. . [**6-23**] ruq us:1. no focal fluid collections. 2. atrophic right kidney consistent with chronic renal failure. . [**2167-6-30**] 4:18p other blood chemistry: hbsag: negative hbs-ab: negative hbc-ab: negative [**2167-4-29**] 05:41pm report comment: source: line-hemodialysis hepatitis hepatitis b surface antigen negative hepatitis b surface antibody positive hepatitis b virus core antibody negative hepatitis c serology hepatitis c virus antibody positive brief hospital course: discharge summary (as of [**2167-5-27**]) assessment and plan: this is a 53 year old woman with coronary artery disease, congestive heart failure, copd, pulmonary hypertension, s/p l aka who is oxygen dependent on nasal canula 4 liters at home, and polysubstance abuse who presented to [**hospital3 35813**] center in [**state 792**]with altered mental status, hypoxia, and agitation. she was intubated for airway protection and transferred to [**hospital1 18**]. course complicated by anuric renal failure requiring dialysis. . 1)mental status change: most likely multifactorial, as patient with previous polysubstance abuse. chronic small vessel disease noted on head ct. eeg negative for seizure activity. per family, patient lives alone and able to care for herself and perform activities of daily living. on admission, toxicology screen revealed opiates and tricyclics, and by medical notes on transfer, patient had been using more sedating medications than normal. neurology evaluated patient and vitamin b12 and folate levels were normal. she received thiamine. tsh level was elevated to 8 and her t4 was only very slightly below normal. thus, thyroid function was not attributed to altered mental status. an eeg revealed encephalopathy, but no seizures. ct head revealed chronic small vessel disease. lp and mri were deferred. -upon extubation, patient slowly became more alert, first with purposeful eye tracking and then by following simple commands. she received haldol and ativan, which sedated her profoundly for several days. then, after extubation, she began to have conversations but with frequent outbursts with cursing at times, poor attention and short term memory. she became febrile on [**2167-5-7**], which was concerning for a line infection, and was treated initially with vanco/zosyn changed to vanco/meropenem plan for 3 day course complete [**2167-5-9**]. c. diff negative x3. her head ct was unchanged. on [**5-13**], patient had her picc line and tunneled hd line placed and developed fevers within 12 hours. only one blood culture from [**5-14**] revealed one bottle of staph coagulase negative organisms. treated with ten day course of vancomycin (per hd protocol) through [**5-23**]. -lexapro was restarted on [**2167-5-12**], but held on [**5-22**]. psychiatry continued to follow patient and for continued outbursts recommended haldol 0.5mg po/iv three times daily. as above, concern that heavy sedatives with ativan and haldol cause profound sedation. she required soft wrist restraints for prevention of line removal. pt was transferred to the micu on [**6-2**] for respiratory compromise (see below). -upon arriving at the floor on [**6-5**] the patient was aox3, but with residual confusion, impulse control issues, and aggitation. her course was complicated by recurrent episodes of aggitation and anxiety which were hard to control. she perseverated on her medications, her course, and her dietary restrictions. psych was consulted and attempted to help control these outbursts without using benzodiazepems. she often complained of dyspnea, but requested ativan as treatment. she was transferred to the micu for low o2 saturation, where she was diuresed for congestive heart failure/volume overload. she was transferred back to the floor on [**6-15**], where she continued to be anxious and take off her o2 mask. psych recommended continuing standing haldol as well as 100mg neurontin qhs. benzodiazepines were avoided. this combination had a calming effect and the patient was significantly less agitated without being over-sedated, thought to be back to her baseline mental status. remained at baseline mental status for the rest of the hospitalization . 2) respiratory compromise: at outside hospital, patient was hypoxic to high 80's on 3l. at home, she requires 4l nasal canula. patient has history of copd, chf, and pulmonary hypertension per outside notes. intubated on transfer and thought that congestive heart failure contributed to hypoxemic event. no clear pneumonia. patient was aggressively diuresed via hemodialysis. she was extubated on [**5-7**]. hypoxia seems out of proportion to edema demonstrated on imaging. tte was negative for patent foramen ovale. . on [**2167-6-1**], the patient triggered for hypoxia 68% on 6 liters (the patient formerly had been 90-92% on 6 liters. on recheck, the o2 sat was 88% and then 90-91% on 6 liters without intervention. the patient was scheduled to have hd as scheduled on [**2167-6-2**]. . at hd, the hd catheter was noted to be nonfunctioning. tpa was tried without success. then, the patient was found to be hypoxic to 75% at hd with abg 7.53/26/44 0on a 40% venti mask. on a nrb, the patient's saturations improved to 97% and a repeat gas was 7/53/27/58. . the patient denied any chest pain and says the shortness of breath was not acute in onset but had been developing over the past few days. however, her sbp was noted to be 188-216 during hd and the patient was given her am bp meds as a result. cxr indicated volume overload and pt. was thought to have had acute pulmonary edema [**1-9**] hypertension and inability to dialyze. pt was transferred to micu and had temporary femoral hd line initially placed, then tunneled hd line placed by ir [**6-3**]. she had 7l removed during micu course with improvement of oxygenation and was sent back to floor [**6-5**]. . while on the floor she was maintained on 6l of nc. she did occasionally complain of dyspnea and anxiety, however it was hard to differentiate this from her psychiatric issues, as she was often breathing at a normal rate and sat'ing in the mid 90s while complaining. she generally maintained saturations from 88-95%. she did have at least two desat's into the low 80s at night, but responded within minutes to reassurance and haldol without changing any pulmonary medications or oxygen. on [**6-9**] she had an episode of somlenence and increased confusion after her haldol had been increased to 2mg/dose and her nc o2 dropped to 4l. she was somlenent but arousable, and still oriented to self she recovered mental status quickly after a 50% venti mask was placed, and was then seen by the micu staff. she was transferred again to the micu at that point, and again was diuresed aggressively with good result. repeat tte again showed no patent foramen ovale/shunt. cta was negative for pe. . she was transferred back to the floor on [**6-15**], where she continued to required 6-8 l o2 and occasionally desat'd in setting of anxiety. an echo [**6-19**] showed evidence of worsening chf (ef 30% now, was >55% in [**month (only) **]), which would explain continued increased oxygen requirement and sob, with evidence of pulmonary edema on cxr. in conjunction with the renal team, the patient required almost daily hd or ultrafiltration to draw off fluid. attempts were made with medications to balance the need for afterload reduction with supporting a blood pressure which could tolerate volume loss through dialysis. this primarily involved decreasing the patient's betablocker and verapamil dose significantly, while maintaining isosorbide nitrate. the patient was witnessed several times eating high salty foods, and being non-compliant with the fluid restriction which complicated attempts to manage her volume status. with aggressive hd, as well as improved management of her anxiety and aggitation (above) the patient gradually was weaned down to her baseline requirement of 4l o2 on nasal cannula. . 3) anuric renal failure: atn likely from tca/opiate overdose. outside hospital records revealed creatinine of 4.0 in [**month (only) 958**] [**2166**]. on admission, anuric. she was hyperkalemic, so initially received kayxelate, calcium gluconate, insulin, and bicarbonated. no ecg changes. renal ultrasound negative for obstruction. received aggressive hemodialysis sessions. there was concern that tunneled dialysis line infected, but as she was not rigoring and did not ever develop fever or hypotension except when on dialysis, believed that filter on hemodialysis machine may have caused adverse reaction. asaghi filter used on [**5-22**] with good effect. . management of the patient's volume status was complicated by dietary noncompliance and aggitation. after requiring 2 micu transfers from the floor due to decreased oxygen saturation from pulmonary edema, we were finally able to dialyze her sufficiently to bring her back to baseline oxygen requirement. we monitored her intake carefully and impressed upon her the importance of dietary compliance. adding neurontin to her anxiety regimen helped calm her and she became more compliant with our management strategy and was less likely to take off her oxygen support. renal recommends performing a 24 hour urine collection after one month to re-evaluate her renal status. . 4) cardiovascular: --ischemia: history of coronary artery disease. as outpatient, on aspirin but no beta blocker or ace-inhibitor. ecg without ischemic changes and initial cardiac enzymes negative. continued aspirin and added beta blocker. --pump: evidence of pulmonary edema and congestive heart failure on admission. as anuric, removed excess fluid with hemodialysis. --rhythm: remained in sinus rhythm. started on beta blockade. --hypertension: severely elevated blood pressures. started amlodipine, metoprolol, and isorbide. goal blood pressure <170, but due to longstanding hypertension, developed worsened mental status when blood pressures less than 140. most likely due to hypoperfusion. in setting of hypotensive episodes during dialysis, held antihypertensives on mornings of dialysis. over the course of hospitalization, we adjusted her bp medications according to what was tolerated during dialysis. on discharge, she is taking isosorbide mononitrate 30mg sr and toprol xl 100mg q day. . 5) gi: on admission, apparent ugi bleeding. coffee grounds in ngt but this was in setting of supratherapeutic inr. subsequently resolved status post reversal of inr. treated with iv (and then po) protonix. her serial hematocrits remained stable. abdominal ct on [**5-1**] unremarkable. diverticulosis was noted on subsequent abdominal ct (as above). . 6) infectious disease: on admission, received levofloxacin, but then broadened to zosyn and vancomycin for uti. completed seven day course on [**5-5**]. shortly after discontinuation of antibiotics, was transiently febrile, so started meropenem and vancomycin on [**5-7**] for 3 day course. picc line was placed and tunneled hd line placed on [**5-13**]. febrile shortly after line placed (1/4 bottles with staph coagulase negative), so started ten day course of vancomycin that was completed on [**5-23**]. new picc placed [**6-3**] for antibiotics and question of infection. on [**6-17**] id was consulted for rising leukocytosis. bacillus species grew from [**6-19**] picc blood cx, pt was started on cefepime for bacteremia on [**6-20**] (initial culture result said gnr) and picc was d/c'd. was discovered on [**6-23**] that bacillus likely was a contaminant. pt has been afebrile, but given persistently high wbc, there was concern for infection or other etiology. [**6-18**] culture from hd catheter had no growtn. c. diff was negative. antibiotics were discontinued on [**6-23**] given no organism isolated and patient being afebrile. subsequent culture from [**6-24**] showed no growth to date. can consider other cause of leukocytosis: patient was not on systemic steroids so that is unlikely to be a cause. patient had mediastinal lymphadenopathy and lung nodules, which could suggest a malignant cause. recommend working up malignancy as outpatient given that patient is clinically stable and would benefit from rehab placement. . 7) depression: on outpatient lexapro. restarted during hospitalization, but discontinued, per psychiatry, on [**5-22**]. . 8) prophylaxis: patient on sc heparin (was on coumadin as outpatient, but unclear reason), lansoprazole, bowel regimen, and thiamine. . 9) access: picc placed on [**5-13**], but removed [**5-22**]. tunneled hemodialysis catheter placed on [**5-13**]. picc placed [**6-3**], removed [**6-21**]. . 10) fen: initially on tubefeeds. speech and swallow evaluation on [**5-18**] cleared patient for thin liquids and pureed solids. aspiration precautions. eventually advanced to regular renal diet. occasionally was hyponatremic, thought due to excess free water ingestion. was kept on fluid restriction 1l/day, with varying effect as patient would sometimes obtain water/fluids when the nurse was not looking. . 11) rash: patient noted to have morbilliform rash on trunk and flank on evening of [**5-25**]. most likely result of drug reaction. potentially vancomycin. started on hydrocortisone cream, sarna lotion, and triamcinolone cream. resolved. pt also noted to have intragluteal irritation with sattelite lesions, likely yeast infection. started on miconazole powder. . 12) code: full. confirmed with daughter. (in the past patient had said she wanted to be dnr/dni but then reversed this). . communication: daughter, [**name (ni) **] - [**telephone/fax (1) 72819**]. . dispo: to . has outpatient hd slot at [**location (un) 37361**] for mwf. medications on admission: unsure of doses--from [**hospital1 **] records 1.aspirin 2.hydralazine 3.imdur 4.amytriptyline 5.lexapro 6.ativan 7.advair 8.combivent 9.albuterol 10. lasix 11. coumadin 12. cardizem discharge medications: 1. aspirin 325 mg tablet [**hospital1 **]: one (1) tablet po daily (daily). 2. polyvinyl alcohol-povidone 1.4-0.6 % dropperette [**hospital1 **]: [**12-9**] drops ophthalmic prn (as needed). 3. lansoprazole 30 mg tablet,rapid dissolve, dr [**last name (stitle) **]: one (1) tablet,rapid dissolve, dr [**last name (stitle) **] daily (daily). 4. docusate sodium 100 mg capsule [**last name (stitle) **]: one (1) capsule po bid (2 times a day) as needed: hold for diarrhea. 5. senna 8.6 mg tablet [**last name (stitle) **]: one (1) tablet po bid (2 times a day) as needed: hold for diarrhea. 6. lactulose 10 g/15 ml syrup [**last name (stitle) **]: thirty (30) ml po q8h (every 8 hours) as needed: hold for diarrhea. 7. albuterol sulfate 0.083 % (0.83 mg/ml) solution [**last name (stitle) **]: one (1) inhalation q4h (every 4 hours) as needed for wheezing. 8. acetaminophen 325 mg tablet [**last name (stitle) **]: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 9. thiamine hcl 100 mg tablet [**last name (stitle) **]: one (1) tablet po daily (daily). 10. b complex-vitamin c-folic acid 1 mg capsule [**last name (stitle) **]: one (1) cap po daily (daily). 12. fluticasone-salmeterol 250-50 mcg/dose disk with device [**last name (stitle) **]: one (1) inh, disk with device inhalation [**hospital1 **] (2 times a day). 13. budesonide 0.25 mg/2 ml solution for nebulization [**hospital1 **]: one (1) neb inhalation [**hospital1 **] (2 times a day). 14. nystatin 100,000 unit/ml suspension [**hospital1 **]: five (5) ml po qid (4 times a day). 15. isosorbide mononitrate 30 mg tablet sustained release 24 hr [**hospital1 **]: one (1) tablet sustained release 24 hr po daily (daily). 16. haloperidol 1 mg tablet [**hospital1 **]: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for anxiety or aggitation. 17. albuterol sulfate 0.083 % (0.83 mg/ml) solution [**hospital1 **]: one (1) neb ih inhalation q6h (every 6 hours) as needed. 18. tramadol 50 mg tablet [**hospital1 **]: one (1) tablet po q12h (every 12 hours) as needed. 19. lidocaine 5 %(700 mg/patch) adhesive patch, medicated [**hospital1 **]: one (1) adhesive patch, medicated topical q24h (every 24 hours). 20. ipratropium bromide 0.02 % solution [**hospital1 **]: one (1) neb inhalation q6h (every 6 hours) as needed. 21. haloperidol 2 mg tablet [**hospital1 **]: one (1) tablet po tid (3 times a day). 22. zolpidem 5 mg tablet [**hospital1 **]: 1-2 tablets po hs (at bedtime). 23. miconazole nitrate 2 % powder [**hospital1 **]: one (1) appl topical qid (4 times a day) as needed. 24. sevelamer 400 mg tablet [**hospital1 **]: one (1) tablet po tid w/meals (3 times a day with meals). 25. gabapentin 100 mg capsule [**hospital1 **]: one (1) capsule po hs (at bedtime): hold for oversedation. 26. toprol xl 100mg tablet [**hospital1 **]: one (1) tablet po once a day discharge disposition: extended care facility: banister house discharge diagnosis: congestive heart failure , acute on chronic renal failure discharge condition: discharge to banister house in [**hospital1 789**], ri, stable, afebrile, good po intake, wheelchair bound [**1-9**] amputation discharge instructions: please seek medical attention for shortness of breath, chest pain, dizzyness, headache please take your medications as prescribed. followup instructions: please get a repeat chest ct in 6 months to monitor the r upper and middle pulmonary nodules. . please get a 24 hour urine test to evaluate your kidney in one month completed by:[**2167-7-2**]",1
8,"admission date: [**2115-9-6**] discharge date: [**2115-9-10**] date of birth: [**2051-7-18**] sex: f service: medicine allergies: no known allergies / adverse drug reactions attending:[**first name3 (lf) 4095**] chief complaint: melena major surgical or invasive procedure: egd [**2115-9-6**] and [**2115-9-9**] colonoscopy [**2115-9-9**] history of present illness: 64f w/pmhx paf on pradaxa (history of l mca stroke, poor compliance with coumadin, ~20% stroke risk), p/w melena x 3d and some epigastric discomfort. pt reports that she has had mild epigastric burning sensation, accompanied by black stools. she reports that she is moving her bowels ~3x daily, but that there is no diarrhea or large volume stools. she went to her pcps office who noted that she was orthostatic 117-->90 and dizzy and had melena on exam and she was sent to the ed. she was seen in clinic on [**9-6**], when she was noted to have bp of 90/60 with dizziness. black heme positive stool was noted in the rectal vault. she was subsequently sent to the ed for evaluation. in ed, bp 102/58, p 74. pt had scant black stool on exam. she was typed and crossed for 2 units of blood, and started on a protonix gtt. in the ed her initial vital signs were: 98.0 74 102/58 14 98% ra. exam was notable for melena per rectum, abdominal exam was benign. hct was 28 with most recent in our system of 45. she did not tolerate ng tube so no lavage was performed. she was type and crossed for 2u prbc and started on a ppi bolus and drip. she was otherwise stable and transferred to the micu for furhter management of her ugib in the setting of anticoagulation with praxada. on arrival to the micu the patient has no complaints. she reports that she had 3 days of melena. has no history of gi bleeds, no history of ulcers, and no recent nsaid use or aspirin use. she denies any smoking or alcohol use. she reports decreased po intake over the past day and a half due to no appetitie but denies nausea or vomiting. no abdominal pain, no diarrhea. of note her last colonoscopy was in [**2108**] and showed diverticula. on arrival to the floor, patient had stable hct and vitals. she denied any bloody stools, hematochezia, hematemesis, hemoptysis, dizziness/lightheadedness, fevers/chills, n/v/d, abdominal pain. she stated that she felt well and wanted to go home. past medical history: -hypercholesterolemia -paroxysmal atrial fibrillation -right shoulder pain [**2099**] -secondary amenorrhea [**2089**] -thromboembolic stroke- cardiac embolus to l mca territory in [**2113**] while on aspirin. has been on pradaxa since then. -cardiac cath [**2110**]- normocoronaries social history: 1ppd until [**2113**] when she quit no drugs no alcohol use brother recently passed away works at [**hospital1 2177**] as a circulating nurse . family history: brother has history of ulcers, liver cirrhosis, and alcoholism. mom had afib, esrd, and adverse reaction to coumadin physical exam: admission physical exam general: alert, oriented, no acute distress, pale appearing heent: sclera anicteric, conjunctival pallor, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: rrr< no mrg appreciated lungs: ctab, moving good air bilaterally abdomen: soft, minimally tender to palpation in the epigastrium, non-distended, bowel sounds present, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact discharge physical exam vitals t: 97, bp: 112/70, hr: 58, rr: 16, sat: 99% ra general: nad, comfortable heent: mmm, decreased hearing to l ear neck: supple, no jvd appreciated, no ld cv: rrr, no m/g/r lungs: ctab, no crackles/wheezes/rhonchi, unlabored respirations abdomen: soft, nt, nd, +bs, no guarding/rebound ext: wwp, 2+ pt pulses, no edema neuro: a&ox3, moving all extremities, normal gait pertinent results: admission labs [**2115-9-6**] 10:08am blood wbc-9.1 rbc-3.27*# hgb-9.8*# hct-29.2*# mcv-89 mch-29.9 mchc-33.5 rdw-13.7 plt ct-272 [**2115-9-6**] 10:08am blood neuts-75.1* lymphs-18.9 monos-4.9 eos-0.5 baso-0.6 [**2115-9-6**] 10:08am blood pt-14.1* ptt-44.2* inr(pt)-1.3* [**2115-9-6**] 10:08am blood glucose-131* urean-51* creat-1.0 na-140 k-3.8 cl-105 hco3-27 angap-12 [**2115-9-6**] 10:08am blood albumin-3.8 calcium-9.1 phos-3.4 mg-1.9 [**2115-9-6**] 03:17pm blood hct-27.5* [**2115-9-6**] 09:31pm blood hct-25.7* [**2115-9-7**] 02:42am blood wbc-7.5 rbc-3.04* hgb-9.1* hct-26.9* mcv-89 mch-30.1 mchc-34.0 rdw-13.9 plt ct-207 [**2115-9-7**] 11:57am blood hct-27.6* discharge labs: [**2115-9-10**] 06:35am blood wbc-5.0 rbc-3.30* hgb-9.8* hct-29.8* mcv-90 mch-29.7 mchc-33.0 rdw-14.4 plt ct-291 [**2115-9-10**] 06:35am blood glucose-116* urean-10 creat-1.0 na-140 k-4.0 cl-105 hco3-25 angap-14 [**2115-9-10**] 06:35am blood calcium-8.7 phos-3.8 mg-2.1 urine [**2115-9-6**] 10:08am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-sm [**2115-9-6**] 10:08am urine rbc-<1 wbc-2 bacteri-few yeast-none epi-13 transe-1 imaging ct abdomen [**2115-9-7**]: no extraluminal contrast or findings to suggest enterobiliary fistula. egd [**2115-9-6**]: -abnormal mucosa in the stomach -abnormal mucosa in the stomach -mild erythema in duodenal bulb -in the second portion of the duodenum, a large diverticulum was noted. within this diverticulum, there was a black/green mass that had the appearance of a large gallstone. this was adherent to the mucosa. attempts were made to dislodge the mass with flushing and gentle advancement of the endoscope without success. a portion of this material was removed via rothnet for pathological analysis. clinical appearance was suggestive of gallstone ileus versus erosion of gallbladder into duodenum. a portion of this material was removed via [**doctor last name **] net [**2115-9-6**] pathology: consistent with a mixed-type calculus; examined grossly and microscopically. egd [**2115-9-9**] angioectasia in the duodenal bulb (thermal therapy) diverticulum in the second part of the duodenum small hiatal hernia colonoscopy [**2115-9-9**] multiple diverticula were seen in the sigmoid colon and distal descending colon. impression: diverticulosis of the sigmoid colon and distal descending colon recommendations: in hospital care. capsule endoscopy. brief hospital course: ms. [**known lastname **] is a 64 yo f w/ pmh of paroxysmal atrial fibrillation complicated by a left mca thromboembolic stroke without any residual deficits who was anticoagulated with pradaxa and presented to her pcps office with melena x 3days and found to have a duodenal diverticula with mass that appeared to be a gallstone. #upper gi bleed- patient presented with melena and hct drop from 45-->29.2 (from 2 years prior) and orthostatic. this was in the setting of being on pradaxa and had no known preciptants of nsaids, alcohol, or smoking. she was admitted to the icu for urgent egd and monitoring given her need for continued anticoagulation. egd showed no ulcers or gastritis and there was a divericula in the 2nd part of the duodenum with a green/black mass that appeared to be a gallstone and was biopsied. pathology showed a mixed-type calculus. she was transfused 1u prbc with inappropriate bump in hct and was monitored in the icu prior to being transfered to the floor. when patient was transferred to the floor, she had stable vital signs and hematocrit. she reported that her stools were non-bloody and looked brown. she underwent a repeat egd and a colonoscopy. the egd showed a single small angioectasia that was not bleeding in the duodenal bulb. a gold probe was applied for tissue destruction successfully. a single non-bleeding diverticulum with large opening was found in the second part of the duodenum. a small hiatal hernia was also seen. the colonoscopy showed diverticulosis of the sigmoid colon and distal descending colon. since no source of the gi bleeding was identified a capsule study was recommended, which the patient had the following day. she tolerated the capsule study without any problems. [**name (ni) **] hematocrit remained stable at around 27-29 throughout the rest of her hospitalization. on discharge, she felt well and denied any bloody stools or melena. she was discharged with a ppi. #paroxysmal afib- patient has been on pradaxa prior to admission. she has a history of paroxysmal afib with a subsequent stroke while on aspirin. her chads2 score is only a 2, however given it was for a stroke she requires lifelong anticoagulation. on admission, her pradaxa was discontinued and she was started on a heparin drip as a bridge after her egd was performed to reduce her risk of stroke. her pradaxa was discontinued in the meantime. based on discussions with her cardiologist, dr. [**last name (stitle) **], it was recommended to start coumadin and discontinue pradaxa. given her risk of bleeding, patient should be on an anticoagulant that can be closely monitored and reversed to prevent future gi bleed especially since the source of bleeding could not be identified by egd and colonoscopy. this was fully explained to ms. [**known lastname **]. there were several discussions with the patient regarding the risk of bleeding by restarting pradaxa and our recommendation of starting coumadin. however, patient's mother had an adverse reaction to coumadin and she refused to start coumadin, thinking that she will definitely have the same reaction. we attempted to reassure the patient several times that adverse side effects are rare and that she will be closely monitored while on coumadin, but she continued to refuse the medication. given her ugib in the setting of pradaxa and her continuous refusal to start coumadin, dr. [**last name (stitle) **] recommended restarting on pradaxa at a lower dose (from 150mg to 75mg [**hospital1 **]). the risk of a stroke at this lower dose was explained to the patient. she acknowledged full understanding of the risks of continuing with pradaxa (increased risk of bleeding if she returns to her previous dose and increased risk of stroke at the lower dose). she also acknowledged understanding of why we thought coumadin was a better choice -- a decreased risk of both bleeding and having a stroke while on the appropriate dose of coumadin. she believed that the potential adverse reaction of coumadin outweigh the benefits. therefore, she was discharged with 75mg pradaxa and bridged with lovenox. she will follow up with her cardiologist, dr. [**last name (stitle) **], in one month. #hyperlipidemia -continued on home simvastatin # transitional issues []results of capsule study. gi will call patient with the results of the capsule study and will arrange appropriate follow up. []after several discussions with the patient, also involving her cardiologists, patient refused to start coumadin. she was thus restarted on pradaxa but at a lower dose (75mg) to prevent future gi bleed. medications on admission: preadmission medications listed are correct and complete. information was obtained from patientwebomr. 1. dabigatran etexilate 150 mg po bid 2. metoprolol tartrate 25 mg po tid 3. propafenone *nf* 325 mg oral [**hospital1 **] extended release 4. simvastatin 40 mg po daily discharge medications: 1. metoprolol tartrate 25 mg po tid 2. simvastatin 40 mg po daily 3. propafenone *nf* 325 mg oral [**hospital1 **] extended release 4. dabigatran etexilate 75 mg po bid rx *pradaxa 75 mg 1 capsule(s) by mouth twice a day disp #*60 tablet refills:*0 5. pantoprazole 40 mg po q12h rx *pantoprazole 40 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*0 discharge disposition: home discharge diagnosis: primary diagnosis: upper gi bleeding secondary diagnosis: afib, hypercholesterolemia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. [**known lastname **], it was a pleasure taking care of you during your hospitalization at [**hospital1 69**]. you were admitted because you had black stools that was positive for blood. your blood count also decreased due to a bleeding in your intestinal tract and you needed a transfusion. you had an endoscopy and colonoscopy that showed a single small angioectasia that was not bleeding and was treated with thermal therapy. you also had a capsule study to help identify the source of the bleeding. the results of the capsule study will take about 8 days. please follow up with the gastroenterologist for the results of your capsule study. you should avoid nsaids and aspirin because they can increase your risk of bleeding. you can restart taking pradaxa (but at a lower dose) twice a day to prevent clots. followup instructions: the gastroenterologist will call you with the results of your capsule study. you should also call [**telephone/fax (1) 463**] to set up an appointment with a gastroenterologist. you should follow up with your cardiologist, dr. [**last name (stitle) **] in one month. his office will call you with the details of the time and date of the appointment. you should also call your primary care physician, [**last name (namepattern4) **]. [**last name (stitle) **], to set up an appointment. completed by:[**2115-9-12**]",1
9,"admission date: [**2153-3-19**] discharge date: [**2153-3-29**] date of birth: [**2089-5-11**] sex: m service: medicine allergies: no known allergies / adverse drug reactions attending:[**first name3 (lf) 5141**] chief complaint: gu bleed major surgical or invasive procedure: hemodialysis with temporary line paracentesis kidney biopsy history of present illness: 63-year-old male with hep c cirrhosis and hcc who was admitted for new arf (creatinine 11.9 up from 1.1 on [**3-8**], k max on day of admission was 6.2) after recently moving to [**location (un) 86**]. he started hd yesterday which he tolerated well and then underwent left renal biopsy today at 11:30. he got ddavp for plts of 65 in setting of liver failure. he then began having hematuria. from discussion with nursing over the course of the afternoon he may have had up to 660cc of frank looking blood out his foley. he never became tachycardic. he was seen by urology who began cbi. he was having bladder pain. he also received 200cc ivf with the plan to have it taken off by hd at a later time. during hd he dropped his sbp to 70s and hd was discontinued for labile pressures. yesterday during dialysis his sbp were only as low as 80s. he lives at a sbp of 90s per the patient. he never was tachycardic today. hct this am 39.8 this am and was 25.5 this afternoon. hct was 39.6 on arrival to the hospital but likely baseline is 30. he received the beginning of a blood transfusion on the floor but became hypothermic and developed rigors. blood transfusion was stopped. pt states blood always needs to be specially prepared for him. hct on arrival to the unit was 20.4. inr today was 1.4. . he has hcc [**2-14**] hepatitis c complicated by esophageal varices s/p banding, anemia requiring transfusion, portal gastropathy, and ascites requiring intermittent paracenteses. his most recent chemotherapy was from was sorafenib between the dates of [**2153-1-22**] and [**2153-3-6**]. he had stopped his chemo at that time due to an admission for a gi bleed. he had banding of a non actively bleeding variceal bleed at that time. . on arrival to the icu vitals were t95.8 sbp98/50 hr66 rr14 100% ra. the pt reported he was feeling much better. all bladder discomfort and rigors has resolved. past medical history: onc hx: -[**2150-11-19**]: resection of 4x4x3.8cm liver lesion in segment 5. pathology consistent with hcc. no lymphovascular invasion -[**2151-5-20**]: resection of 1.8cm lesion in segment 5 -[**2152-2-14**]: chemoembolization of a branch of right hepatic artery with taxotere and embospheres for two right lobe lesions measuring 1.5 and 0.5 cm along with microwave ablation of the 1.5cm lesion -had been on transplant list when mri [**2152-8-11**] showed 2.4 x 4.3cm lesion in segment 8 and thrombosis of a portal vein branch. underwent biopsy of the lesion which revealed a moderately differentiated hepatocellular carcinoma with tumor embolus in the portal vein branch. afp started rising, 232ng/ml. delisted from transplant list. -attempt to enroll in search trial. however, pt had anemia (despite d/c-ing internferon and ribavarin), making him ineligible from study -began radiation in [**11/2152**] and finished 01/[**2153**]. since [**2153-1-22**] he has been on sorafenib 400mg [**hospital1 **]. afp steadily increasing over last 5 months to 3000s. -required large volume paracentesis twice [**2-/2153**] (7.6l and 7.8l). episodes of anemia secondary to gi bleeding. egd and colonoscopy performed, revealing esophageal varices, hemorrhoids and mild portal gastropathy. -hospital admission [**2153-3-5**] for drop in hct for which he received prbcs. no site of bleeding identified. . other past medical history: htn ? chf social history: recently moved from [**state 531**] to [**location (un) 86**] to be near his son. lives alone but son lives ten minutes away. worked in the past as sheet metal worker but now retired. denies hx of smoking, etoh or illicit drug use, including iv drugs. family history: father: cirrhosis, etoh physical exam: exam on admission: vs: 95.5 88/50 60 20 100%ra gen: aox3, nad heent: perrl. mmm. no lad. no jvd. neck supple. no cervical, supraclavicular, or axillary lad cards: rrr s1/s2 normal. no murmurs/gallops/rubs. pulm: no dullness to percussion, ctab no crackles or wheezes abd: bs+, distended, moderate ascites, nt, no rebound/guarding, liver enlarged to 2cm below costal margin, no [**doctor last name 515**] sign extremities: wwp. 3+ b/l edema, l > r, left calf pain, dps, pts 2+. skin: no rashes or bruising neuro: cns ii-xii intact. 5/5 strength in u/l extremities. no asterixis exam on discharge: vs: 98.2 120/64 66 16 97%ra gen: aox3, nad heent: perrl. mmm. no lad. no jvd. no [**doctor first name **]. cards: rrr s1/s2 normal. no murmurs/gallops/rubs. pulm: no dullness to percussion, ctab no crackles or wheezes abd: bs+, distended, moderate ascites, nt, no rebound/guarding, liver enlarged 2cm below costal margin extremities: wwp. 2+ b/l edema, l > r skin: no rashes or bruising, anicteric neuro: cns ii-xii intact. 5/5 strength in u/l extremities. no asterixis. pertinent results: admission labs: [**2153-3-19**] 11:00am blood wbc-11.6* rbc-3.94* hgb-12.4* hct-39.6* mcv-100* mch-31.5 mchc-31.4 rdw-19.0* plt ct-113* [**2153-3-19**] 11:00am blood pt-17.6* inr(pt)-1.6* [**2153-3-19**] 11:00am blood gran ct-8810* [**2153-3-19**] 11:00am blood urean-141* creat-11.9* na-134 k-5.2* cl-101 hco3-16* angap-22* [**2153-3-19**] 11:00am blood alt-30 ast-65* ld(ldh)-170 alkphos-244* totbili-1.3 dirbili-0.8* indbili-0.5 [**2153-3-19**] 11:00am blood totprot-7.7 albumin-2.6* globuln-5.1* calcium-8.2* phos-11.8* mg-2.0 [**2153-3-19**] 11:00am blood afp-2802* [**2153-3-19**] 06:15pm blood c3-83* c4-15 [**2153-3-20**] 07:10am blood hcv ab-positive* discharge labs: [**2153-3-29**] 07:02am blood wbc-6.4 rbc-2.98* hgb-9.4* hct-29.0* mcv-97 mch-31.5 mchc-32.4 rdw-19.4* plt ct-95* [**2153-3-29**] 07:02am blood pt-13.5* ptt-30.8 inr(pt)-1.2* [**2153-3-25**] 05:50am blood lupus-neg [**2153-3-25**] 05:50am blood aca igg-pnd aca igm-pnd [**2153-3-29**] 07:02am blood glucose-92 urean-74* creat-2.9* na-135 k-4.2 cl-99 hco3-29 angap-11 [**2153-3-24**] 06:00am blood alt-24 ast-64* ld(ldh)-155 alkphos-183* totbili-1.5 [**2153-3-29**] 07:02am blood albumin-2.5* calcium-8.9 phos-4.6* mg-1.8 [**2153-3-21**] 06:00am blood hapto-120 [**2153-3-19**] 06:38pm blood cryoglb-positive * [**2153-3-20**] 07:10am blood hbsag-negative hbsab-positive hbcab-positive [**2153-3-19**] 06:15pm blood anca-negative b [**2153-3-19**] 06:15pm blood [**doctor first name **]-positive * titer-1:640 [**2153-3-19**] 06:15pm blood rheufac-<3 [**2153-3-19**] 11:00am blood afp-2802* [**2153-3-19**] 06:15pm blood pep-polyclonal [**2153-3-28**] 10:36am blood c3-97 c4-17 [**2153-3-27**] 06:44pm blood free kappa and lambda, with k/l ratio-pnd [**2153-3-19**] 02:19pm urine u-pep-multiple p ife-no monoclo osmolal-378 [**2153-3-19**] 02:19pm urine hours-random creat-198 na-40 k-31 cl-14 totprot-44 prot/cr-0.2 [**2153-3-26**] 03:53pm ascites wbc-50* rbc-52* polys-11* lymphs-13* monos-68* mesothe-8* [**2153-3-26**] 03:53pm ascites totpro-0.9 glucose-125 ld(ldh)-27 albumin-less than microbiology: urine culture (final [**2153-3-20**]): no growth. blood culture, routine (final [**2153-3-25**]): no growth. blood culture, routine (final [**2153-3-27**]): no growth. mrsa screen (final [**2153-3-24**]): no mrsa isolated. [**2153-3-26**] 3:53 pm peritoneal fluid gram stain (final [**2153-3-26**]): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final [**2153-3-29**]): no growth. anaerobic culture (preliminary): no growth. studies: [**2153-3-19**] gu u/s: impression: 1. normal kidneys. 2. enlarged prostate gland with calculated volume of 37.4cc. 3. large volume intra-abdominal ascites. [**2153-3-20**] bilateral lenis: impression: bilateral normal lower extremity us. negative for above-knee dvt bilaterally. [**2153-3-22**] ct abdomen/pelvis: impression: 1. mild perinephric stranding adjacent to the left kidney, most likely from recent percutaneous biopsy. a small hyperdense focus in the posterior aspect of the left kidney likely represents a tiny hematoma. 2. hyperdense blood within the left collecting system, including the proximal ureter, with no evidence of obstruction. there is a large amount of blood and clot within the bladder. there is no large hematoma outside of the collecting system. 3. massive abdominal ascites. 4. multiple irregular hypodensities within the liver, incompletely characterized on this non-contrast enhanced study, compatible with multifocal hcc, better seen on prior reference imaging studies. 5. mediastinal and porta hepatis lymphadenopathy. 6. colonic diverticulosis. [**2153-3-21**] kidney biopsy: ultrasound guidance for renal biopsy by nephrologist: ultrasound examination of the kidneys was performed. the lower pole of the left kidney was identified and the position was marked on the patient's back for renal biopsy to be performed by the nephrologist. [**2153-3-21**] cxr: opacification in infrahilar right lung is probably atelectasis, unchanged. there are no findings to suggest current pneumonia. heart size is normal. no pleural abnormality. right jugular line ends in the region of the superior cavoatrial junction. [**2153-3-26**] peritoneal fluid: negative for malignant cells. [**2153-3-26**] paracentesis: impression: successful ultrasound-guided diagnostic and therapeutic paracentesis of 3 liters of serous fluid. [**2153-3-27**] ct abdomen/pelvis: impression: 1. unchanged hyperdense focus in the posterior left kidney, consistent with a small subcapsular hematoma. 2. decreased amount of hyperdense blood and clot both within the proximal left collecting system and the bladder. no hematoma is seen outside of the collecting system. 3. large amount of abdominal ascites. 4. incompletely characterized irregular hypodensities within the liver consistent with the patient's known multifocal hcc. brief hospital course: 63-year-old male with hep c cirrhosis and hcc with new onset acute renal failure and transferred to the unit for gu bleed after left renal biopsy. # acute renal failure: cr was elevated on admission to 11.9 from baseline 0.9. renal was consulted and advised dialysis as well as a kidney biopsy. he received several sessions of bedside hemodialysis; two sessions were prematurely stopped as his blood pressure did not tolerate it. cr came down to 4.2 following dialysis and further trended down to 2.9 prior to discharge. his lasix was held given his acute renal failure and hypotension. his other antihypertensives, amlodipine and aldactone, were also held. renal ultrasound showed enlarged prostate and large amount of ascites but normal kidneys. initially, it was felt that his acute renal failure was secondary to sorafenib induced nephrotoxicity. however, the kidney biopsy light microscopy showed mesangial proliferative gn. immunofluorescence showed 2+ igg and 2+ lambda mesangial deposition. there were no thrombi in the microvasculature to make deifinite diagnosis of a tma to implicate the sorafenib. spep showed polyclonal hypergammaglobulinemia and upep showed no monoclonal ig and was negative for bence [**doctor last name 49**] proteins. the serum free light chain assay was pending on discharge. [**country 7018**] red was negative for amyloid. his [**doctor first name **] was also positive at 1:640, lupus anticoagulant was negative, and anti-cardiolipin igg/m were pending at discharge. preliminary biopsy results were suspicious for fibrillary glomerulonephritis. he was discharged with follow-up at nephrology clinic for further evaluation as outpatient. he was discharged on sevelamer for hyerphosphatemia. he was also restarted on his lasix as cr stabilized. # gu bleed s/p kidney biopsy: pt underwent kidney biopsy on [**2153-3-21**] that was complicated by gross hematuria. he was seen by urology and put on cbi. his hematuria led to drop in hct from high 20s to low 20s and a drop in blood pressure to systolic 70s. he was transferred to the icu for the hypotension. ct abdomen showed perinephric stranding adjacent to the left kidney, most likely from recent percutaneous biopsy, a small hematoma in left kidney, and blood in the collecting system and bladder. he required a total of 5 units prbcs and 1 bag platelets throughout hospital admission. hct was stable at baseline in high 20s by time of discharge. repeat ct abdomen showed that small hematoma in kidney was stable. he no longer had hematuria at discharge and was able to urinate without a foley. # ?transfusion reaction: of note, pt exhibited rigors during his first transfusion. he was not febrile. per transfusion medicine, this was likely not a febrile non-hemoltyic transfusion reaction given the short duration of his symptoms, no subsequent fever and that leukoreduction significantly decreases the risk of these reactions. he experienced no adverse reactions from his subsequent transfusions. # hypotension: bp at admission was systolic 80s. he was given iv fluids and his antihypertensives and diuretics were held (with the exception of nadolol). he later became hypotensive to systolic 70s following hematuria after a kidney biopsy and hemodialysis. pt also with mild hyperthermia to 95 concerning also for infection on admission. he was pan-cultured, with negative urine and blood cultures. patient started on ctx 2gm q24hrs x2 days for possible sbp, but was dicscontinued [**3-23**] as likelihood of sbp felt to be very small with no abdominal pain, normal wbc and no fevers. peritoneal fluid showed no signs of infection. following transfusion of prbcs and iv fluids, bp stabilized in systolic 100s-120s throughout remainder of admission. # le edema: pt presented with le edema, left worse than right. on admission he endorsed some calf pain as well. b/l lenis were obtained, which were negative for dvt. pain resolved and pt was able to ambulate without difficulty. he was discharged back on his lasix. # hepatocellular carcinoma: pt was s/p sorafenib [**2153-1-22**] to [**2153-3-6**]. he has recently transferred his onc care here. he was continued on nadolol at admission but this was briefly held in the icu when gi bleed was being ruled out for drop in hct. he underwent a therapeutic paracentesis on [**2153-3-26**]; peritoneal fluid was benign and 3l were removed from abdomen. he will discuss with his outpatient oncologist whether sorafenib can be restarted once kidney function stabilizes. medications on admission: 1. oxycodone 5mg po q4h prn 2. aldactone 100mg po daily 3. lasix 40mg po daily 4. nadolol 20mg daily 5. protonix 40mg daily 6. amlodipine/benzapril 10/40 7. nexavar (on hold) 8. levaquin 500mg po x 1 week discharge medications: 1. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 2. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 3. nadolol 20 mg tablet sig: one (1) tablet po daily (daily). 4. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 5. sevelamer carbonate 800 mg tablet sig: one (1) tablet po tid w/meals (3 times a day with meals). disp:*90 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: acute renal failure secondary: hepatocellular carcinoma discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure taking care of you in the hospital. you were admitted with acute kidney failure. the severity of your kidney failure required several sessions of hemodialysis. your kidney function improved with the hemodialysis. you were evaluated by our renal consult team who performed a kidney biopsy. this was complicated by bleeding that caused your blood counts to drop and your blood pressure to drop. you were transferred to the intensive care unit briefly because of this and were transfused with blood products. your blood pressure recovered and the bleeding in the urine stopped. your kidney biopsy showed a rare condition called fibrillary glomerulonephritis. it is very important that you have regular follow-ups at the [**hospital 10701**] clinic for frequent monitoring of your kidney function and possibly further testing. the following medications were changed: 1) stop amlodipine/benzapril unless one of your outpatient doctors wants to restart. your blood pressure was extremely good in the hospital so you didn't need it on discharge. 2) stop aldactone. ask your outpatient doctors when [**name5 (ptitle) **] [**name5 (ptitle) **] restart this medication. 3) stop levaquin 4) stop nexavar 5) start sevelemar 800mg three times a day with meals to lower your phosphorous levels followup instructions: you have the following appointments scheduled for you. you will need to come to the [**hospital 2793**] clinic on the [**location (un) 448**] of the [**hospital ward name 121**] building ([**hospital ward name **]) on monday [**2153-4-2**] to get your labs drawn. please come between the hours of 9am and 2pm and bring with you the lab order slip. department: hematology/oncology when: friday [**2153-4-6**] at 3:30 pm with: [**last name (lf) 3150**],[**name8 (md) **] md [**telephone/fax (1) 11133**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) 24**] campus: east best parking: [**hospital ward name 23**] garage department: west [**hospital 2002**] clinic when: wednesday [**2153-4-4**] at 2:30 pm with: [**first name8 (namepattern2) **] [**last name (namepattern1) **] [**name8 (md) **], 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 completed by:[**2153-3-29**]",0
10,"admission date: [**2119-5-30**] discharge date: [**2119-7-2**] date of birth: [**2100-12-27**] sex: m service: medicine allergies: penicillin g / ceftriaxone / phenytoin / meropenem attending:[**first name3 (lf) 2291**] chief complaint: seizure major surgical or invasive procedure: [**2119-5-31**]: burr hole and abscess aspiration [**2119-6-21**] left craniotomy drainage of brain abscess [**2119-6-28**] re-do left craniotomy drainage of brain abscess history of present illness: 18 y/o m in good health first presented to osh [**5-27**] following first seizure. pt had generalized seizure, was brought to osh where ct head was in itially interpreted as normal, and patient started on po dilantin. plan for outpatient mri. the patient had no neurologic deficits, constitutional symptoms, or other findings at that time, per report. he returned home, and had progressively worsening headaches over the past 2 days. earlier today, the patient had 2 generalized seizures and was taken again to an osh where ct head with iv contrast demonstrated a 2.5 cm ring enhancing mass in the left temparoparietal lobe. the patient had a temperature of 101.9 at the osh and was administered iv ctx/vanco/flagyl. upon arrival to [**hospital1 18**], the patient is awake and responsive, interviewed in spanish. he describes headaches, but otherwise denies any recent problems. [**name (ni) **] his mother, he usually speaks and undedrstands some english, but has been unable to do so over the past 3 days. past medical history: denies. no history of pediatric infections, recurrent infections. social history: immigrated from [**country 13622**] republic. lives with family. no recent travel. does not use illicit substances, does not inject drugs. family history: non-contributory physical exam: admission: t: 99.4 bp: 130/64 hr:90 r:18 o2sat:100/2l-nc awake and alert cooperative with exam names [**1-10**] objects in spanish makes paraphasic errors and neologisms poor repetition pupils equally round and reactive to light extraocular movements intact bil without abnormal nystagmus facial strength and sensation intact and symmetric hearing intact to voice palatal elevation symmetrical sternocleidomastoid and trapezius normal bilaterally tongue midline without fasciculations normal bulk and tone bilaterally no abnormal movements, tremors strength full power [**5-13**] throughout no pronator drift sensation intact to light touch x 4 ext toes downgoing bilaterally non-dysmetric on finger-nose-finger physical exam upon discharge: afebrile, bp 100s/60s, hr 80s, satting 99%ra general: alert, conversant. skin: peeling skin on arms and legs. no erythema or drainage at picc site. heent: line of staples on left occiput. no erythema or discharge surrounding staples. no facial edema. sclera anicteric, conjunctiva clear. neck: supple, jvp not elevated, no lad lungs: ctab, no wheezes, rales, rhonchi cv: rrr, normal s1 + s2, no m/r/g abdomen: soft, nt, nd, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused (brisk cap refill), 2+ pulses, no clubbing, cyanosis or edema. no lesions on palms or soles. neuro:cn 2-12 intact, sensation throughout, [**5-13**] stregnth throughout. can walk on heels and toes. pertinent results: [**2119-5-30**]: cxr- impression: normal chest. [**2119-5-31**]: mri brain- limited planning study. peripherally t1 hyperintense lesion in the left temporo-parietal lobe with surrounding perilesional edema causing mass effect on the ocipital [**doctor last name 534**] of left lateral ventricle. this has significantly increased in size since the prior ct dated [**2119-5-27**]. the differentials for this includes infection (abscess), inflammatory lesion or tumefactive multiple sclerosis or subacute hematoma. given the short term increase compared to the ct head study of [**2119-5-27**], neoplastic etiology is less likely; however, lymphoma related lesion if the pt. is immunosuppressed cannot be completely excluded. correlate with complete mr imaging an labs. [**5-31**] ct head: immediately status post left parietal burr hole and aspiration of the ring-enhancing lesion with associated vasogenic edema in the left parietal lobe, apparently representing known abscess (according to the given history). there is a small amount of intralesional gas and blood, post-procedure [**6-1**] echo: impression: no valvular vegetations or abscesses appreciated. [**6-1**] panorex: there is no evidence of gross decay or dental infection. his 3rd molars appear to be impacted and may require removal in the future. [**2119-6-16**] head ct impression: interval increase in the size of a left rim-enhancing brain lesion measuring 1.9 x 3.7 x 3.5 cm. [**2119-6-16**] rue u/s impression: no dvt. [**2119-6-17**] ruq u/s impression: normal abdominal ultrasound. no intra- or extra-hepatic bile duct dilation. [**2119-6-18**] mri head w/ contrast conclusion: continued enlargement of the abscess, now with contact with the ventricle and at least subependymal enhancement. [**2119-6-21**] head ct impression: expected post-surgical changes, immediately after left parietal craniotomy for evacuation of an intracranial abscess. pneumocephalus and small intraparenchymal blood at the resection site with surrounding edema are noted. [**2119-6-23**] cxr impression: no acute chest abnormality. [**2119-6-27**] head mri impression: 1. overall evidence of progression with interval thickening of the abscess cavity, extension of adjacent flair signal and new involvement of the left occipital [**doctor last name 534**] subependyma. 2. no new parenchymal abscesses identified. [**2119-6-29**] head ct impression: expected postoperative changes immediately after left parietal craniotomy for evacuation of intracranial abscess with pneumocephalus, vasogenic edema, and small amount of intraparenchymal blood. [**2119-6-12**] peripheral flow cytometry interpretation: non-specific t cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by b-cell lymphoma are not seen in specimen. correlation with clinical findings and morphology is recommended. abscess cultures [**2119-5-31**] 1:05 pm abscess intercranial. **final report [**2119-6-8**]** gram stain (final [**2119-5-31**]): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. 4+ (>10 per 1000x field): gram positive cocci. in pairs and singly. wound culture (final [**2119-6-8**]): streptococcus anginosus (milleri) group. moderate growth. sensitivity testing performed by sensititre. clindamycin mic <= 0.12 mcg/ml. ceftriaxone sensitivity requested by [**first name4 (namepattern1) **] [**last name (namepattern1) 8021**] [**9-/3768**] [**2119-6-6**]. sensitive to ceftriaxone mic = 0.125mcg/ml, sensitivity testing performed by etest. sensitivities: mic expressed in mcg/ml ________________________________________________________ streptococcus anginosus (milleri) group | clindamycin----------- s erythromycin----------<=0.25 s penicillin g----------<=0.06 s vancomycin------------ <=1 s anaerobic culture (final [**2119-6-4**]): no anaerobes isolated. [**2119-6-21**] 2:00 pm swab abscess. **final report [**2119-6-27**]** gram stain (final [**2119-6-21**]): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. wound culture (final [**2119-6-23**]): no growth. anaerobic culture (final [**2119-6-27**]): no growth. [**2119-6-28**] 10:25 pm swab site: brain left brain abscess deep. gram stain (final [**2119-6-29**]): no polymorphonuclear leukocytes seen. no microorganisms seen. wound culture (final [**2119-6-30**]): no growth. anaerobic culture: ___________________________________________ [**2119-6-28**] 10:15 pm swab site: brain left access point. gram stain (final [**2119-6-29**]): no polymorphonuclear leukocytes seen. no microorganisms seen. wound culture (final [**2119-6-30**]): no growth. anaerobic culture: ___________________________________________ [**2119-6-28**] 10:30 pm swab site: brain left brain abscess 2nd focus. gram stain (final [**2119-6-29**]): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. wound culture: ______________________________________________ anaerobic culture: __________________________________________ [**2119-5-31**] 7:35 am blood (toxo) toxoplasma igg antibody (final [**2119-6-2**]): positive for toxoplasma igg antibody by eia. 29 iu/ml. reference range: negative < 4 iu/ml, positive >= 8 iu/ml. toxoplasma igm antibody (final [**2119-6-2**]): negative for toxoplasma igm antibody by eia. interpretation: infection at undetermined time. [**2119-5-31**] 07:20pm blood aspergillus galactomannan antigen-test - neg [**2119-5-31**] 07:42pm urine histoplasma antigen-test [**2119-5-31**] 07:20pm blood cysticercosis antibody-test - neg [**2119-5-31**] 07:20pm blood b-glucan-test - neg [**2119-6-2**] 10:55am blood hiv ab- negative [**2119-6-10**] 05:17am blood cd5-done cd23-done cd45-done hla-dr[**last name (stitle) 7735**] [**name (stitle) 7736**]7-done kappa-done cd2-done cd7-done cd10-done cd19-done cd20-done lambda-done [**2119-6-14**] 06:40am blood strongyloides antibody,igg-pnd microbiology - blood cultures [**2119-6-23**] 9:00 pm blood culture x 2: no growth [**2119-6-22**] 12:39 pm blood culture x 2: no growth [**2119-6-18**] 10:00 am blood culture x 2: no growth [**2119-6-17**] 3:26 am blood culture x 2: no growth [**2119-6-16**] 8:14 pm blood culture x 2: no growth [**2119-6-15**] 9:02 am blood culture x 2: no growth [**2119-6-9**] 8:44 pm blood culture x 2: no growth [**2119-6-8**] 4:48 am blood culture x 2: no growth [**2119-6-4**] 9:36 pm blood culture x 2: no growth [**2119-5-31**] 7:35 am blood culture x 2: no growth [**2119-5-30**] 11:30 pm blood culturex 2: no growth lfts [**2119-5-30**] 11:30pm blood alt-22 ast-26 alkphos-103 totbili-0.3 [**2119-5-31**] 01:43am blood alt-21 ast-27 alkphos-108 totbili-0.3 [**2119-6-5**] 11:29am blood alt-33 ast-25 alkphos-93 amylase-54 totbili-0.1 [**2119-6-8**] 04:48am blood alt-89* ast-90* alkphos-82 totbili-0.1 [**2119-6-9**] 04:57am blood alt-126* ast-123* [**2119-6-10**] 05:17am blood alt-144* ast-122* ld(ldh)-381* [**2119-6-11**] 05:21am blood alt-158* ast-109* [**2119-6-12**] 05:34am blood alt-179* ast-82* [**2119-6-13**] 05:49am blood alt-173* ast-70* alkphos-112 totbili-0.3 [**2119-6-14**] 06:39am blood alt-173* ast-55* alkphos-116 totbili-0.4 [**2119-6-15**] 06:07am blood alt-117* ast-29 alkphos-105 totbili-0.4 [**2119-6-16**] 05:44am blood alt-125* ast-40 [**2119-6-17**] 03:27am blood alt-249* ast-136* ld(ldh)-494* ck(cpk)-36* alkphos-89 totbili-0.3 [**2119-6-19**] 05:53am blood alt-185* ast-30 [**2119-6-20**] 05:00am blood wbc-12.4* rbc-3.99* hgb-11.8* hct-36.0* mcv-90 mch-29.5 mchc-32.7 rdw-13.1 plt ct-317 [**2119-6-21**] 05:47am blood alt-229* ast-72* alkphos-104 [**2119-6-22**] 04:57am blood alt-240* ast-56* alkphos-117 totbili-0.3 [**2119-6-23**] 08:16am blood alt-175* ast-47* alkphos-111 totbili-0.5 [**2119-6-25**] 04:04am blood alt-123* ast-33 alkphos-104 totbili-0.4 [**2119-6-26**] 02:13am blood alt-113* ast-31 alkphos-106 totbili-0.3 [**2119-6-27**] 05:34am blood alt-106* ast-33 alkphos-104 totbili-0.4 urinalysis [**2119-6-24**] 04:40pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.5 leuks-neg [**2119-6-23**] 08:58pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-tr [**2119-6-18**] 06:10am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-neg [**2119-6-16**] 04:34pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-neg [**2119-6-4**] 09:37pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-tr brief hospital course: 18yo m with no pmh admitted for seizures, fever and ams, found to have brain abscess, cultures positive for s. anginosus s/p i&dx3; treatment course complicated by multiple drug allergies, and red man syndrome in setting of vancomycin infusion. # brain abscess: pt initialy given vancomycin/ceftriaxone/flagyl for broad coverage and on [**2119-5-31**], the pt unerwent burr hole and aspiration without complication. pt given dilantin and keppra for seizure prophylaxis initialy. brain abscess grew out strep anginosus. pt had thorough workup to investigate etiology: panorex of teeth, tte, tee and ct a+p. ct a+p showed cecal thickening and typhlitis, possibly the original source of infection, although pt denied every having gi symptoms. after patient's initial post-op course, he developed daily fevers up to 103 ultimately attributed to antibiotic drug reaction. see below for antibiotic course. after a trial of several antibiotics, it was felt that he had a beta-lactam allergy and he was ultimately switched to vancomycin and flagyl which he ultimately tolerated well. pt had repeat head imaging (head ct [**6-16**], head mri [**2119-6-18**]) which demonstrated enlargement of the abscess. the patient was then taken for a second i&d ([**2119-6-21**]), via mini craniotomy. the patient tolerated this procedure well, and returned to the medicine floor that day. post-operative neurologic exam was within normal limits. of note, abscess cultures were negative (including fungi and anaerobes). repeat imaging on [**6-27**] with mri suggested possible extension of the abscess again. the patient underwent third i&d on [**2119-6-28**]. no pus or abscess was found during this procedure (washings were negative) and his prior mri findings were likely attributed to post-op changes rather then progressing abscess infection. pt remained neurologically intact. #surgical interventions for abscess the pt underwent mutiple i&ds for s. anginosus brain abscess: [**2119-5-31**], [**2119-6-21**], [**2119-6-28**]. pt is due to get staples removed early [**2119-7-9**] (10 days since most recent i+d). # pharmacologic treatment of abscess/red man syndrome/b-lactam allergy: the pt was treated with numerous antimicrobial agents. treatment course was complicated by drug-induced rashes and fevers. pt was placed on empiric antibiotic therapy with vanc/ceftriaxone/flagyl until speciation was determined. pt was then switched to penicillin g. due to rash, penicillin was discontinued and he was then switched to ceftriaxone/flagyl. patient's rash worsened and he had daily high fevers 103, and he was then switched to meropenem. rash temporarily abated, but returned worse than before (morbilliform from head to toe, also with fevers). meropenem was discontinued and pt was placed on vancomycin/flagyl. during his initial vancomycin infusion ([**2119-6-16**]), pt developed characteristic 'red man syndrome' with cehst pain, pruritis, redness, agitation during the infusion. the patient was transferred to the micu for further observation and his vancomycin infusion rate was slowed down. he was initialy given solumedrol during his vanco infusions and that was then stopped as his clinical picture and rash improved. he was maintained on vancomycin (slow infusion over 3 hrs) and flagyl for the remainder of his hospital course and tolerated this well. the patient was discharged on vancomycin and flagyl, four week course from the date of third i&d ([**7-1**]- [**2119-7-26**]). pt will continued to get weekly cbc with diff, bun, cr, vanco trough, and close follow up with id and neurosurgery. # vancomycin infusion reaction: during patient's vancomycin infusion ([**2119-6-16**]), the patient became acutely agitated, tachypneic, and complained of worsened pruritus and sudden-onset chest pain with redness throughout body. the patient was diagnosed with ""red man syndrome."" the patient was transferred to the micu for supervision of further infusions. infusion rate was slowed (over 3hours). he was initialy ""pre-treated"" with diphenhydramine and methylprednisolone prior to vanco infusion, to further reduce rash and pruritus. methylprednisolone was eventually discontinued and patient tolerated vancomycin slow infusions without difficulty. # transaminitis: the patient had intermittently elevated lfts. transaminitis was likely due to drug reaction (phenytoin vs beta-lactams). ruq u/s and abdominal ct demonstrated no abnormalities, and bilirubins were normal. lfts trended down and stabalized while on vancomycin and flagyl. # eosinophilia: the patient had a eosinophilia, coincident with rash and transaminitis. eosinophilia was attributed to drug allergy. work up was negative for helminth infection, etc. # seizure prophylaxis: the pt had an apparent seizure after his first i&d. he was placed on phenytoin and levacetiram for seizure prophylaxis. due to concerns that phenytoin was contributing to his rash, fevers, and transaminitis, phenytoin was discontinued later in the hospital course. the patient was maintained on levacetiram throughout. he will follow up with neurosurgery to determine when he can stop this medication. # general infectious work-up: the patient underwent a thorough infectious work-up, including panorex xray, dental consult, tte, tee with bubble study, abdct, serial blood cultures, and assays. abdominal ct with contrast was notable for typhlitis and prominent mesenteric, periaortic, inguinal and femoral lymph nodes. testicular exam was normal. flow cytometry was negative for a lymphoma/leukemia. true etiology of his strep anginosus brain abscess was unclear. [**name2 (ni) **] ct a+p showed typhlitis, pt denied every having abdominal symptoms. transitional issues: -needs staples removed [**2119-7-9**] -will require 4 weeks of antibiotics as of [**7-1**]- [**2119-7-26**]. pt will get weekly opat labs sent to [**hospital **] clinic. -currently on keppra 750mg [**hospital1 **] for seizure prophylaxis. -has allergy to b-lactams: morbilliform rash, lfts, fevers medications on admission: none discharge medications: 1. acetaminophen 650 mg po q6h:prn pain, headache or t > 38.3 do not exceed 4g/day 2. levetiracetam 750 mg po bid rx *levetiracetam 750 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*2 3. vancomycin 1250 mg iv q 8h infuse over 3 hours 4. metronidazole (flagyl) 500 mg po q8h rx *flagyl 500 mg 1 tablet(s) by mouth three times a day disp #*30 tablet refills:*4 rx *metronidazole 500 mg 1 tablet(s) by mouth q 8 hrs disp #*90 tablet refills:*1 5. sarna lotion 1 appl tp [**hospital1 **] rx *sarna anti-itch 0.5 %-0.5 % apply liberally to areas of rash and peeling skin twice a day disp #*600 milliliter refills:*1 6. heparin flush picc line maintenance and heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent. flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 7. outpatient lab work check once a week: cbc with diff, bun, cr, vanco-trough. fax to dr. [**first name4 (namepattern1) **] [**last name (namepattern1) **] [**telephone/fax (1) 17715**]. 8. vancomycin vancomycin 1250 mg iv q 8h. infuse over 3 hours. disp: 4 week's supply. premedicate with benadryl 25mg po. 9. diphenhydramine 50 mg po q8h give prior to vancomycin dose hold for sedation rr < 12 discharge disposition: home with service facility: [**last name (lf) 486**], [**first name3 (lf) 487**] discharge diagnosis: intracranial abscess hyperexia tonic clonic seizures beta lactam allergy ""red man syndrome"" discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. [**known lastname 111991**], thank you for the privilege of participating in your care. you were admitted to the [**hospital1 69**] because you were found to have an infection in your brain (an ""abscess""). we still do not know where this infection came from. we do not know why you developed this infection in your brain. we performed a very thorough workup to investigate where this infection might have come from. a ct scan of your abdomen showed a possible inflammation or infection which might have been the original source of infection. the imaging of the teeth, chest, heart, rest of your body is all reassuring. the brain abscess required treatment with surgery and antibiotics. after your first surgery, imaging showed that the infection could be getting bigger. for this reason, you had to have two more surgeries. the most recent surgery was reassuring that the infection appears to be gone at this time. laboratory cultures from the first surgery showed infection with bacteria. cultures from the second and third operation did not grow any bacteria, indicating that the antibiotics were treating the infection well. also, the neurosurgeons did not see any infection during the third surgery. this is strong evidence that the infection is disappearing. during your hospitalization, you had a very itchy rash, and many high fevers. the rash and fevers were most likely caused by the antibiotics you took after your first surgery. these antibiotics that you seem to have an adverse reaction to are: penicillin, ceftriaxone and meropenem. you are currently on vancomycin and flagyl antibiotics that are fighting the infection. you are tolerating these medications well. you will need to continue the vancomycin and flagyl for a total 4 week course since your last surgery. thus, you should take it through [**7-26**]. the infectious disease doctors [**name5 (ptitle) **] [**name5 (ptitle) 111992**] [**name5 (ptitle) **] when to stop these medications. when you leave the hospital, it is very important that you continue to take all antibiotics as prescribed. if you do not take all your medicines, it is possible that the infection could come back. a nurse will come to your home to help you with the medications. it is also important to take the medication keppra, 1 pill twice a day. this medication will prevent seizures. you should continue this medication until the neurosurgeons tell you that you can stop. it will likely be for several months. please schedule an appointment with your primary care doctor, dr. [**last name (stitle) **]. also, please go to the appointments scheduled with the neurosurgery and infectious disease teams. it is very important that you go to these appointments. your doctors [**name5 (ptitle) 9004**] to be sure that you continue to recover well. you will also have more imaging of your head, to be sure that the infection is getting smaller. here are some instructions from the neurosurgery team: - your sutures should stay clean and dry until they are removed. - do not wash your head where the wound is until [**7-8**]. (10 days after surgery) at that point you can then wash your hair. ?????? have a friend or family member check the wound for signs of infection such as redness or drainage daily. ?????? exercise should be limited to walking; no lifting >10lbs, straining, or excessive bending. ?????? do not take any anti-inflammatory medicines such as motrin, aspirin, advil, or ibuprofen etc. until follow up. ?????? do not drive until your follow up appointment. followup instructions: follow-up appointment instructions ??????please call ([**telephone/fax (1) 4676**] to schedule an appointment with one of the physician assistant in [**7-18**] days from the time of surgery for staple removal ([**7-9**] you will be due to have the sutures removed). ??????you will need a ct of the brain with contrast in the future. you have an appointment scheduled on [**7-19**] per the neurosurgeons. [**telephone/fax (1) 1669**] is the office phone number for the neurosurgeons. please see appointment time and date below. ?????? you need to follow up with infectious disease on [**7-5**] with dr [**first name8 (namepattern2) **] [**last name (namepattern1) 724**] and dr. [**first name4 (namepattern1) 636**] [**last name (namepattern1) **]. you need the following labs sent weekly to them: cbc with diff, bun, cr, vanco trough, fax to: dr [**first name4 (namepattern1) 636**] [**last name (namepattern1) **] [**telephone/fax (1) 1419**]. the visiting nurses will be notified to do this for you. department: infectious disease when: wednesday [**2119-7-5**] at 11:30 am with: [**first name4 (namepattern1) **] [**last name (namepattern1) 8021**], md [**telephone/fax (1) 457**] building: lm [**hospital ward name **] bldg ([**last name (namepattern1) **]) [**hospital 1422**] campus: west best parking: [**hospital ward name **] garage department: radiology when: wednesday [**2119-7-19**] at 9:15 am with: cat scan [**telephone/fax (1) 590**] building: cc [**location (un) 591**] [**location (un) **] campus: west best parking: [**street address(1) 592**] garage department: neurosurgery when: wednesday [**2119-7-19**] at 10:45 am with: [**name6 (md) **] [**name8 (md) **], md [**telephone/fax (1) 1669**] building: lm [**hospital unit name **] [**location (un) **] campus: west best parking: [**hospital ward name **] garage [**2119-7-21**], 8:30am infectious disease office [**hospital **] medical building, [**last name (namepattern1) 439**], basement [**telephone/fax (1) 457**] [**2119-8-17**] 8:00am with dr [**last name (stitle) 1206**]. neurologist. [**hospital ward name 23**] building clinical center, [**location (un) **].",1
11,"admission date: [**2146-9-16**] discharge date: [**2146-10-7**] date of birth: [**2098-10-13**] sex: f service: medicine allergies: demerol / compazine / reglan / betadine surgi-prep / tape / iodine; iodine containing / vancomycin attending:[**first name3 (lf) 2195**] chief complaint: hypotension, septic shock major surgical or invasive procedure: esophagoduodenoscopy (egd) transesophageal echocardiography (tee) left femoral hickman line replacement history of present illness: patient is a 47 yo f with [**location (un) **] syndrome s/p colectomy, repeated small bowel resections, and resultant short gut syndrome on tpn since [**2123**] c/b with multiple line infections and clotted veins. she was recently admitted on [**2146-8-23**] to the [**hospital unit name 153**] for sepsis. although no clear source was found, she was streated iwht iv fluconazole and daptomycin for her history of fungemia and multiple line infections. she had a tee that was negative for endocarditis. she was discharged on [**2146-9-2**] on daptomycin and fluconazole. of note, during this hospitalization, she had new word-finding difficulties and a noncontrast head ct demonstrated a new interval focus of hypodensity in the l basal ganglia, concerning for acute to subacute ischemia, and new subtle hypodensity at the left cerebellum, also concerning for acute ischemia. however, she could not tolerate cts with contrast or mris so no further imaging was performed. neurology felt her symptoms did not correlate with the ct findings. today she presented to the ed with painful petechie all over her hands, feet, and legs. her mother took her vs this morning at 10am, which were 100.5, 119, 98/60, 28. she had bilious vomiting and was shaking. she was noted to have large petechiae on her entire body, including pams and soles. in the ed, initial vs: 98.5, 128, 98/64, 20, 96 on ra. she was dropping her sbp in 60s-70s, which somewhat responded to 3l ns. she received meropenam and is ordered for daptomycin and micafungin per id. ir has been notifed of new line needs and will take her case next. current vs are: afeb, 82/49, 112, 19, 97-100% on 4l. ros: denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, brbpr, melena, hematochezia, dysuria, hematuria. past medical history: ++ [**location (un) **] syndrome - diagnosed age 23 - total colectomy, end ileostomy [**2121**] - small bowel resection (multiple) secondary to recurrent polyposis - subsequent short gut syndrome - on tpn since [**2123**], [**9-/2131**] ++ benign cystadenoma - partial hepatectomy, [**2131**] ++ line-associated blood stream infections - her cvl in her l leg has been in place for at least 5 years, when she has had infections the line has been changed over a wire as pt has limited remaining access (l groin vessels and hepatic vessels are only usable vessels). - mssa, [**2127**] - [**first name5 (namepattern1) 564**] [**last name (namepattern1) 563**] [**12/2139**] - c. parapsilosis + coag neg staph, [**2-/2140**] - [**female first name (un) 564**] non-albicans, [**3-/2141**] - c.parapsilosis, [**9-/2142**] - k. pneumoniae, [**9-/2145**] --> resistant to cipro, cefuroxime, tmp/smx --> treated with meropenem [**date range (1) 110935**]/08 - line change due to positive blood cultures (?) [**10/2145**] --> had an echocardiogram that was abnormal as noted below coag neg staph [**1-/2146**] --> line changed over wire --> linezolid [**date range (1) 110936**] --> coag neg staph [**6-2**], no line change, on dapto till [**2146-6-28**] - admitted to [**hospital1 18**] [**2145-9-27**] with history of + urine for vre isolated on [**2145-9-8**] at healthcare [**hospital 4470**] hospital. ++ venous thrombosis/occlusion - failed access in r ij, r brachiocephalic - reconstructed ivc w/ kissing stent extensions into high ivc - stenting to r femoral, external iliac ++ gi bleed ++ hsv-1 ++ fibromyalgia ++ osteoporosis ++ scoliosis; h/o surgical repair ++ right hip fracture; orif [**2129**] ++ meniscal tears of knee; 4 prior surgeries, [**2133**] ++ total abdominal hysterectomy; bilateral salpingo-oophorectomy ++ dermoid cyst removal (small bowel, ovaries) ++ hepatic cyst adenoma; resected ++ cholecystectomy, [**2131**] . previous microbiology(selected positive results): [**2146-6-17**] ucx: klebsiella and pseudomonas (? contaminated) [**2146-6-10**] ucx: klebsiella [**2146-6-1**]: bcx: malassezia species. [**2146-2-24**] bcx: [**female first name (un) **] albicans social history: the patient lives with her mother in [**name (ni) 20157**], mass; mother helps her with her medical needs. pt also has pcas who she has hired to help with care. denies alcohol or tobacco. sister, [**name (ni) 3235**], is very involved in her care and likes to be updated frequently. family history: father and 6 of 8 siblings with [**location (un) **] syndrome. mother and relatives with htn and resulting cva. sister with breast cancer. her father's parents died of cancer. physical exam: t 98.1 bp 104/72 p 93 rr 20 o2sat 100% 2lnc gen: middle-aged woman, in mild discomfort heent: nc/at, eomi, mmm, supple neck, no lad chest: cta b/l, no wheezing/rales cv: rrr, nl s1s2, no m/r/g abd: soft, nt, nd, +bs, ostomy c/d/i ext: no c/c/e, +dp pulses access: l femoral hickman nonerythematous, nontender skin: dark petechiae on finger and toes pertinent results: admission labs [**2146-9-16**]: [**2146-9-16**] 12:45pm wbc-2.0* hgb-10.3* hct-31.6* plt ct-148*# [**2146-9-16**] 12:45pm neuts-64 bands-18* lymphs-14* monos-1* eos-2 baso-0 atyps-0 metas-0 myelos-1* [**2146-9-16**] 12:45pm hypochr-normal anisocy-occasional poiklo-occasional macrocy-normal microcy-occasional polychr-1+ ovalocy-occasional stipple-occasional [**2146-9-16**] 12:45pm pt-14.2* ptt-34.5 inr(pt)-1.2* [**2146-9-16**] 12:45pm glucose-90 urean-24* creat-1.5* na-135 k-4.4 cl-103 hco3-21* angap-15 [**2146-9-16**] 12:45pm alt-116* ast-121* alkphos-522* totbili-2.8* [**2146-9-16**] 12:45pm lipase-20 [**2146-9-16**] 12:45pm calcium-8.9 phos-2.2* mg-1.4* [**2146-9-16**] 12:48pm lactate-4.3* [**2146-9-16**] 05:27pm lactate-2.3* u/a: [**2146-9-16**] 02:00pm color-yellow appear-clear sp [**last name (un) **]-1.016 [**2146-9-16**] 02:00pm blood-mod nitrite-neg protein- glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-neg [**2146-9-16**] 02:00pm rbc-[**5-4**]* wbc-0-2 bacteri-rare yeast-none epi-0-2 [**2146-9-16**] 05:20pm color-yellow appear-clear sp [**last name (un) **]-1.012 [**2146-9-16**] 05:20pm blood-lg nitrite-neg protein-25 glucose-neg ketone-neg bilirub-sm urobiln-neg ph-5.0 leuks-neg [**2146-9-16**] 05:20pm rbc->50 wbc-0-2 bacteri-mod yeast-none epi-0-2 [**2146-9-16**] 05:20pm eos-negative [**2146-9-16**] 05:20pm hours-random creat-59 na-117 wbc trend: [**2146-9-16**] 12:45pm wbc-2.0* [**2146-9-17**] 03:43am wbc-8.8# [**2146-9-17**] 11:38am wbc-5.8 [**2146-9-18**] 01:38am wbc-8.3 [**2146-9-19**] 03:52am wbc-5.2 [**2146-9-20**] 04:58am wbc-4.5 [**2146-9-21**] 05:24am wbc-3.7* [**2146-9-22**] 06:57am wbc-4.2 [**2146-9-23**] 06:40am wbc-4.0 [**2146-9-24**] 05:34am wbc-6.2# [**2146-9-24**] 07:15am wbc-6.2 [**2146-9-25**] 05:02am wbc-4.9 [**2146-9-26**] 05:43am wbc-5.3 [**2146-9-27**] 05:53am wbc-4.5 [**2146-9-28**] 06:05am wbc-3.4* [**2146-9-29**] 05:01am wbc-3.4* [**2146-9-30**] 05:10am wbc-3.6* [**2146-10-1**] 05:58am wbc-3.2* [**2146-10-2**] 05:48am wbc-3.0* [**2146-10-3**] 04:20am wbc-2.8* [**2146-10-4**] 05:47am wbc-3.2* [**2146-10-5**] 07:29am wbc-2.4* [**2146-10-6**] 06:39am wbc-2.8* [**2146-10-7**] 06:05am wbc-3.0* other pertinent labs: [**2146-9-17**] 11:38am fibrino-336 [**2146-9-17**] 11:38am fdp-160-320* [**2146-9-18**] 07:28am fibrino-338 [**2146-9-17**] 03:43am blood hapto-99 [**2146-9-22**] 03:45pm aca igg-3.5 aca igm-6.6 [**2146-9-16**] 12:45pm alt-116* ast-121* alkphos-522* totbili-2.8* [**2146-9-17**] 03:43am alt-71* ast-51* ld(ldh)-279* alkphos-323* totbili-0.4 [**2146-9-18**] 01:38am alt-55* ast-34 alkphos-271* totbili-0.7 ck monitoring on daptomycin: [**2146-9-22**] 06:57am ck(cpk)-14* [**2146-9-30**] 05:10am ck(cpk)-10* [**2146-10-6**] 06:39am ck(cpk)-17* microbiology: [**2146-9-16**] bcx: klebsiella pneumoniae | ampicillin/sulbactam-- 16 i cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ =>64 r ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- 16 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s [**2146-9-16**] ucx: negative [**2146-9-16**] bcx: no fungus/mycobacterium [**2146-9-16**] bcx: no growth [**2146-9-16**] mrsa screen: negative [**2146-9-16**] ucx: negative [**2146-9-16**] catheter tip: negative 10/24-26/09 bcx: no growth studies: [**2146-9-16**] ekg: sinus rhythm. overall, low qrs voltages. compared to the previous tracing of [**2146-8-22**] low voltages are now seen in the precordial leads [**2146-9-16**] cxr: improved aeration of bilateral bases with some residual atelectasis. stable low lung volumes and elevation of right hemidiaphragm [**2146-9-17**] ruq u/s: stable prominence of the common bile duct with trace free fluid in [**location (un) 6813**] pouch. these findings are nonspecific and clinical correlation is recommended. [**2146-9-17**] cxr: there is unchanged appearance of the vascular stents. the cardiomediastinal silhouette is unchanged. there is slight increase in the right pleural effusion with potential increase in the right basal atelectasis but note is made that overlying devices are projecting over the right chest and the exam should be repeated for precise evaluation of the right hemithorax [**2146-9-17**] ct abd/pelvis 1. no evidence of large retroperitoneal bleed. 2. extensive perivascular fat stranding and small amount of free fluid within the pelvis which measures simple. 3. right lower lobe consolidation concerning for infection and less likely atelectasis. small bilateral pleural effusions. 4. prominent mesenteric and retroperitoneal lymphadenopathy, not significantly changed. [**2146-9-19**] tte: atrial septal defect with right-to-left flow at rest. moderate tricuspid regurgitation. mild pulmonary artery systolic hypertension. if clinically indicated, a tee would be better able to define the size/site of the atrial septal defect. lvef >55%. [**2146-9-21**] cxr: in comparison with the study of [**9-17**], there is little overall change. vascular stents are again seen. extensive right pleural effusion with atelectatic change in the lower lung is again seen. less prominent opacification is again seen at the left base [**2146-9-23**] cta chest: 1. limited study with no evidence of central pulmonary embolism. 2. waxing and [**doctor last name 688**] multifocal peribronchial and peripheral nodular opacities, most likely infectious or inflammatory in etiology. 3. atelectasis in the right lower lobe, mostly due to persistent elevation of the right hemidiaphragm. 4. mediastinal lymphadenopathy, which could be reactive [**2146-10-4**] tee: patent foramen ovale with bidirectional shunting at rest and anatomy not ideally suited for percutaneous closure. no intracardiac thrombus seen. [**2146-10-4**] ue/le b/l lenis: patent visualized left and right subclavian veins patent left common femoral vein, containing venous catheter. persistent occlusion of the right common femoral vein. discharge labs [**2146-10-7**]: [**2146-10-7**] 06:05pm wbc-3.0* hgb-9.1* hct-27.1* plt ct-288*# [**2146-10-7**] 06:05pm glucose-113 urean-23 creat-0.8 na-139 k-4.1 cl-107 hco3-25 angap-11 brief hospital course: ms. [**known lastname 1557**] is a 47 year old woman with h/[**initials (namepattern4) **] [**last name (namepattern4) **] syndrome, multiple abdominal surgeries, resultant short gut syndrome, on chronic tpn, who presented with sepsis and paradoxical emboli. # klebsiella bacteremia - the patient was admitted to the micu with sepsis, likely [**12-27**] to line infection and was started on daptomycin, meropenem, ciprofloxacin, and micafungin empirically. her left femoral hickman was replaced by ir on [**9-16**]. initial bcx grew klebsiella, sensitive to ceftriaxone, so the patient was started on ceftriaxone - last day [**2146-10-14**]. she was also given daptomycin and fluconazole from a prior infection until [**2146-10-7**]. she was hemodynamically stable and transferred to the floor with no issues. she was afebrile with no increase in wbc count during her hospitalization. she tolerated the antibiotics well. blood cultures from [**date range (1) 51017**] were negative. ucx were negative as well. the patient had a tte on [**2146-9-19**] to look for vegetations - no vegetations were noted. the patient is to follow up in [**hospital **] clinic upon discharge. # anemia: the patient was transfused with 2u prbc in the micu on [**9-17**] for hct 21.4%, with improvement to 29.1%. ct showed no large rp bleed. the patient's hct remained stable during her hosptialization with no further requirement for transfusion. # asd: the patient has a known asd, first noted on echo in [**2139**]. the tte on [**2146-9-19**] showed new r->l shunt, thought to be [**12-27**] to increased pulmonary pressures from untreated pe from [**3-3**]. she was unable to undergo cardiac mri for better characterization, as she has b/l rods implanted in her femurs for prior leg fractures. she had a tee performed on [**2146-10-4**] that better characterized the asd. it was determined to be suboptimal for closure at this point, so the patient was started on anticoagulation to treat her pe and lower pulmonary pressures. she can be re-evaluated in the future if she continues to have paradoxical emboli. # dysphagia: the patient has noted intermittent symptoms of choking for the past year. she was scheduled for outpatient egd for further evaluation, but has missed all of the appointments in the past year [**12-27**] to hospitalizations. she also failed conscious sedation on one occasion as an outpatient. she was able to undergo egd under general anesthesia while an inpatient. she was found to have an esophageal stricture [**12-27**] to reflux esophagitis. she was started on a ppi [**hospital1 **] for treatment. # pe/multiple line-related thromboses: the patient has a h/o of pe from [**2146-2-23**] that was untreated [**12-27**] to failure of ac with coumadin (supratherapeutic inr [**12-27**] to interactions with abx) and lovenox (adverse reaction - painful welts developed on arms and abdomen). she had been on plavix for the past several months. she was admitted with painful petechiae on her fingers/toes and had episodes of word finding difficulties. it is likely that the clots from her lines were traveling through the asd with the new r->l shunt. the asd was determined to be difficult to close, so anticoagulation was re-addressed. the patient was started on fondaparinux for anticoagulation with instructions to monitor closely for any adverse reactions. she also has outpatient follow up scheduled with hematology to determine the best course of anticoagulation. further work-up for other causes of increased clotting was not done, as the patient has clear risks for clot formation from her multiple stents and indwelling line. # leukopenia: the patient was noted to have leukopenia - wbc ~3, possibly from drug reaction. since daptomycin and fluconazole were being discontinued only several days after the wbc was noted to be decreasing, it was decided to continue these drugs until [**2146-10-7**]. wbc on discharge was 3.0. she should have her wbc closely monitored as an outpatient. medications on admission: fentanyl 150 mcg/hr patch 72 hr clopidogrel 75 mg po daily ondansetron 4 mg rapid dissolve po every 4 hours prn fluconazole 400 mg/200 ml daily daptomycin 275 mg q24h lorazepam 0.5 mg po q6h orn morphine 10-20 mg po q4h as needed for pain. discharge medications: 1. outpatient lab work please draw weekly cbc with diff, bun, cr, ast, alt, alkphos, tbili, ck while the patient is on antibiotics. please fax results to dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 111**] at [**telephone/fax (1) 432**]. 2. fondaparinux 5 mg/0.4 ml syringe sig: five (5) mg subcutaneous daily (daily). disp:*30 mg* refills:*0* 3. fentanyl 75 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 4. morphine concentrate 20 mg/ml solution sig: 10-20 mg po every four (4) hours as needed for pain. 5. ethanol (ethyl alcohol) 98 % solution sig: two (2) ml intravenous daily (daily). 6. heparin flush (10 units/ml) 2 ml iv prn line flush tunneled access line (e.g. hickman), heparin dependent: flush with 10 ml normal saline followed by heparin as above daily and prn per lumen. 7. ceftriaxone 1 gram recon soln sig: one (1) g intravenous once a day for 7 days: end [**2146-10-14**]. disp:*7 g* refills:*0* 8. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every four (4) hours as needed for nausea. 9. lorazepam 0.5 mg tablet sig: one (1) tablet po every six (6) hours as needed for anxiety. 10. 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 with service facility: diversified vna and hospice discharge diagnosis: primary diagnosis klebsiella bacteremia esophageal stricture secondary to reflux esophagitis secondary diagnosis pulmonary embolism atrial septal defect [**location (un) **] syndrome discharge condition: stable, improved, afebrile discharge instructions: you were admitted to the hospital with an infection in your blood. your left femoral hickman line was replaced by interventional radiology, and you were started on antibiotic treatment. you have responded well to the antibiotics and have not had any fevers. you were also admitted with painful fingertips and toes, which was caused by blood clots. you had an echocardiogram, which showed that the blood has started shunting from the right to the left side of the heart. this is because of increased pressure in your lung, which is likely due to a blood clot (pulmonary embolus) that has been untreated in your lung since [**2146-2-23**]. you were unable to tolerate treatment with coumadin in the past because it made your blood too thin. lovenox gave you painful welts on your arms and abdomen. you underwent an egd and tee during this hospitalization to evaluate your esophagus and the hole in your heart. you were found to have a stricture in the esophagus, which has been causing you difficulty swallowing for the past year. this can be treated with acid blocking medication. unfortunately, the hole in your heart is not going to be easily repaired. it was thought to be safer to start blood thinners (fondaparinux) to treat the blood clot in your lungs, which will hopefully decrease the pressure in your lungs. the following changes have been made to your medications: 1. start fondaparinux 5mg subcutaneously daily - this is a blood thinner that will help treat the blood clot in your lung, as well as prevent more blood clots from forming. please monitor closely for any adverse reactions to this medication, as you have had an adverse reaction to lovenox (a similar medication) in the past. 2. take ceftriaxone until [**2146-10-14**] to complete treatment for your infection. 3. take pantoprazole twice daily to treat reflux esophagitis if you experience bleeding, fevers, chills, shortness of breath, chest pain, abdominal pain, nausea, vomiting, lightheadedness, or any other concerning symptoms, please call your primary care doctor or return to the emergency department. it was a pleasure meeting you and taking part in your care. followup instructions: the following appointments that have already been scheduled for you: primary care appointment: [**last name (lf) **],[**first name3 (lf) **] a. [**telephone/fax (1) 75498**] date/time: [**2146-10-13**] 3:30pm hematology: md: [**first name8 (namepattern2) **] [**last name (namepattern1) 6944**] date and time: wednesday, [**11-2**], 4:40pm location: [**location (un) **], [**location (un) 436**] phone number: [**telephone/fax (1) 6946**] infectious disease: provider: [**first name8 (namepattern2) **] [**last name (namepattern1) **], md phone:[**telephone/fax (1) 457**] date/time:[**2146-11-4**] 11:30",1
12,"admission date: [**2177-11-25**] discharge date: [**2177-11-26**] date of birth: [**2107-11-9**] sex: f service: micu-green reason for admission: the patient was transferred from outside hospital (vent-core), because of acute renal failure as well as a new serious rash. history of present illness: this is a 70 year old woman with a history of breast cancer, chronic obstructive pulmonary disease, severe refractory hypertension, type 2 diabetes mellitus, and chronic renal insufficiency who presents from [**hospital 103101**] rehabilitation, followed there by the pulmonary interventional fellow, [**name (ni) **] [**name8 (md) **], m.d., with a desquamating rash, serum eosinophilia as well as recent acute renal failure. the patient was discharged to this rehabilitation from [**hospital1 69**] in [**2177-7-10**]. prior to the admission to [**hospital1 346**] medical intensive care unit from [**7-3**] until [**2177-8-1**], she was also here in early [**month (only) **] as well. in the first admission, she was admitted for a chronic obstructive pulmonary disease flare and was noted to have bilateral pleural effusions and pericardial effusions with tamponade physiology. this was tapped under ultrasound guidance and found to be exudative with negative cytology and [**first name8 (namepattern2) **] [**doctor first name **] of 1.160. she was then readmitted nine days later with shortness of breath again, thought to be a chronic obstructive pulmonary disease flare and was treated with nebulizers, lasix and solu-medrol. she was found to have tamponade physiology on a transthoracic echocardiogram, underwent balloon pericardiotomy and intubated for airway protection. an ultrasound guided thoracentesis on [**7-4**] for a left pleural effusion which was found to be transudative was performed and the patient was extubated successfully. five days later, both the pleural effusion and the pericardial effusions reaccumulated requiring re-intubation on [**7-9**]. the patient went to the operating room for a pericardial window, a left chest tube and a left pleurodesis. after this, she was unable to extubate and was then returned to the medical intensive care unit. failure to wean in the medical intensive care unit was secondary to diaphragmatic weakness and she was noted to have critical care polyneuropathy/myopathy per emg on [**2177-7-24**]. she underwent tracheotomy on [**2177-7-17**]. the cause of the pleural and pericardial effusions are unknown. the work-up was basically negative; there were no malignant cells found in either of the fluids and the pericardial window biopsy was negative. also, rheumatology evaluated her and thought it was not secondary to a rheumatological cause because her admission [**doctor first name **] on [**7-6**] was negative (however, she had positive [**doctor first name **] on [**2177-7-25**] times two). her pulmonary status improved and the effusions remained stable so she was discharged to vent-core on [**2177-8-1**]. she did well at the rehabilitation and her course there was actually unknown to us at this point, however, we do know that she was unable to be weaned off of her ventilator. she was currently on cmv with a total volume of 500, respiratory rate of 12 and an fio2 of 40% and had recently failed a ps trial secondary to tachypnea and low volume. recent events at the rehabilitation are summarized below: we know that she recently finished a course of vancomycin and cefepime on [**11-17**], which was begun empirically secondary to a fever. at this time, we do not know the length of time she was on either of these antibiotics. she was recently restarted on lisinopril on approximately [**11-16**]. she does have a history of her creatinine going up on ace inhibitors in the past, however, she was having blood pressures up to the 240s and an attempt was made to restart her on lisinopril which she had not been on since [**month (only) 216**]. her creatinine upon discharge from [**hospital1 190**] ranged from 1.0 to 1.5. she briefly had some elevations of the creatinine into the 2.4 range secondary to acute renal failure from intravenous contrast. they restarted the lisinopril at 10, went up to 20, and discontinued her lisinopril on [**11-20**], as her creatinine had started to rise. it was 3.2 on [**11-21**] and then increased to 3.6 at the outside hospital on [**11-24**]. renal did evaluate her while she was at the rehabilitation and they suggested dialysis as well as an increase in her lasix. she did not undergo dialysis at that time. then, on [**11-21**], a rash was noted to have started that was initially limited and mild but then she underwent desquamation of her skin associated with diffuse erythema and edema. she was also noted to have an eosinophilia since [**2177-10-17**]. we know that her serum eosinophils were 16% on [**11-19**] and had decreased to 12% on [**11-24**]. of note, she had also been on prednisone for an unknown reason. at the rehabilitation it was decided to start weaning this down from 10 mg to 5 mg one week ago. according to the physicians that took care of her at the rehabilitation, her only new medications were lisinopril from approximately [**11-16**] until [**11-20**]. she had been previously on that but not since [**month (only) 216**]. she was also recently started on amlodipine however, it was related that this was started on [**11-22**], after the rash had appeared. all her other hypertensive medications she had been on for quite some time, and the only other recent medications were her antibiotics, vancomycin and cefepime, that were discontinued on [**11-17**], when the course was finished. review of systems: the patient can nod her head with responses and denied pain and shortness of breath at time of admission. past medical history: 1. chronic obstructive pulmonary disease: restrictive lung disease with reactive airway disease. 2. status post tracheostomy on [**7-17**] and peg placement on [**2177-7-28**]. her tube feeds are at a goal of 35 cc per hour. she has been unable to be weaned off her ventilator at vent-core. 3. pericardial effusion / tamponade that was found to be exudative with negative cytologies. status post window placement on [**2177-7-9**]. 4. bilateral pleural effusions, transudative, status post left pleurodesis on [**2177-7-9**]. 5. breast cancer (dcif), status post total mastectomy, er-pos, stage 2, no radiation, n0 m0, and currently off tamoxifen. 6. severe hypertension, on five medications. 7. type 2 diabetes mellitus, previously on oral hypoglycemics and now requiring insulin. 8. chronic renal insufficiency secondary to diabetes mellitus with nephrotic range proteinuria. 9. acute renal failure secondary to intravenous dye in [**2177-7-10**]. also had a history of elevated creatinine secondary to ace inhibitors. 10. thalassemia trait. 11. questionable history of osteogenesis imperfecta. 12. legal blindness; she has a left eye prosthesis as well. 13. urinary incontinence. 14. echocardiogram results from [**2177-6-9**] revealed a right ventricular wall clot/tumor with an ejection fraction of 58%. her latest echocardiogram at [**hospital1 188**] on [**2177-7-22**], revealed an ejection fraction of greater than 65%, mild lae, mild symmetrical left ventricular hypertrophy with normal cavity size and regular wall motion; mild thickened atrial valve and mitral valve leaflets; moderate pulmonary hypertension; small to moderate pericardial effusion predominantly over the right ventricle. no change when compared to the prior study of [**2177-7-17**]. 15. noted to have vancomycin resistant enterococcus in her urine on [**7-23**]. 16. left ocular paresthesia. 17. anemia; it appears that her baseline hematocrit is usually in the high 20s. 18. spap with 2% gamma band, likely consistent with mgus. upap revealed multiple protein bands without even predominating. 19. urine positive for pseudomonas according to the rn at vent-core. 20. history of methicillin resistant staphylococcus aureus - question in her sputum. allergies: no known drug allergies. medications on transfer to [**hospital1 **]: 1. amlodipine 10 mg q. day p.o., recently began on [**11-22**], after the rash had appeared. 2. hydralazine 100 mg four times a day; she has been on this medication for a while. please note that the vent-core sheets report that she began this medicine on [**11-21**], however, this was only a renewal according to dr. [**last name (stitle) **]. 3. lasix 40 mg twice a day. 4. nph 20 units twice a day. 5. h2o 125 cc three times a day. 6. benadryl 25 mg q. eight hours. 7. subcutaneous heparin 5000 twice a day. 8. prednisone 5 mg q. day. 9. protein soy supplement, two scoops in the feeding tube q. eight hours. 10. nepro 3/4 strength tube feeds 35 cc per hour. 11. clonidine 0.3 three times a day. 12. bisacodyl 10 mg q. day p.r.n. 13. regular insulin sliding scale with humulin. 14. lopressor 100 mg four times a day. 15. labetalol 200 mg four times a day. 16. isosorbide dinitrate 40 mg q. eight hours. 17. sublingual nitroglycerin p.r.n. 18. protonix 40 q. day. 19. epogen 40,000 units subcutaneously weekly. 20. brimonidine 0.2% solution, one drop bilaterally q. eight hours. 21. ditolamide one drop solution to each eye three times a day. 22. ativan 1 mg q. eight hours. 23. calcium carbonate 500 mg q. eight hours. 24. ipratropium and albuterol mdi four puffs q. four hours p.r.n. allergies: the patient has no known drug allergies. social history: remote history of tobacco use. no current alcohol use. she has a sister who is demented. she previously had lived with her son and her son whose name is [**name (ni) **] [**name (ni) 16093**] is her primary contact, [**telephone/fax (1) 103102**]. he also has a brother, [**name (ni) **] [**name (ni) **], who is a second contact, whose phone number is [**telephone/fax (1) 103103**]. physical examination: temperature 98.4 f.; heart rate 62; blood pressure 163/43, respiratory rate 12 to 18, 100% o2 saturation; vent settings are assist control, total volume 500, respiratory rate 12, o2 saturation 40% with 5 of peep. in general, the patient opens eyes, nods yes and no to questions. she is an elderly african american female. heent: she has a left eye paresthesia, right eye with questionably sclerae clouded over. sclerae anicteric. oropharynx is clear; there are no mucosal lesions. mucous membranes were moist. neck: tracheostomy is in place. neck is supple. cardiovascular: regular rate and rhythm, normal s1 and s2. respirations: decreased breath sounds at bases. occasional wheeze heard in the left anterior aspect of the well healed abdomen. normoactive bowel sounds. peg is in place. soft, nontender, nondistended. extremities with plus two pitting edema diffusely with no cyanosis or clubbing. extremities are warm; plus two dorsalis pedis is felt on the left, however, could not detect distal pulses on the right extremity. skin: as described by the dermatologic consultation later in the evening; generalized moderate non-colorous erythema with marked desquamation and areas that show evidence of good re-epithelialization. multiple eroded areas in the intertrigous areas of the neck, axillae, breasts and groin. approximately 30% of her back showed superficial erosions and skin sloughing. positive perianal punched out ulcers. also of note, the conjunctivae appears slightly erythematous but on gross examination there were no conjunctival or corneal erosions. neurologic: moves all four extremities. pertinent laboratory: from vent-core on [**11-19**], white blood cell count 24, hematocrit 29.2, platelets 329, mcv of 65 with a differential of 72% polys, 5% lymphocytes, 6% monocytes, 16% eosinophils and 1% basophil. from vent-core on [**11-24**], revealed a sodium of 134, potassium of 4.4, chloride of 103, bicarbonate of 22, bun of 130, a creatinine of 3.6 (was 2.4 on [**11-21**] and 3.2 on [**11-19**]). glucose of 111, calcium of 8.6. reportedly had a serum eosinophil percentage of 12. upon admission to [**hospital1 69**], white blood cell count 13.2, hematocrit of 30.1 with an mcv of 66, platelets of 315, pt of 14.4, inr of 1.4, ptt of 28.3. sodium of 135, potassium of 4.9, chloride of 102, bicarbonate of 20, bun of 135, creatinine of 3.6, glucose of 201, calcium of 9.0 corrected to 10.1, phosphorus of 3.4, magnesium of 2.5. alt of 14, ast 22, ld of 233, alkaline phosphatase of 166 which is mildly elevated. total bilirubin of 0.5, albumin of 2,6, lipase of 14, amylase of 20. studies were: 1) portable chest x-ray revealed fairly marked enlargement of the cardiac silhouette. predominantly left ventricle. pulmonary [**hospital1 56207**] are predominant in the upper zones and some left ventricular failure cannot be excluded. loss of translucency at both lung bases; left diaphragm is elevated. tracheostomy is in satisfactory position. probably bilateral pleural effusions with the question of a left lower lobe infiltrate/atelectasis. 2) renal artery ultrasound from [**2177-6-9**] at [**hospital1 346**] was notable to have a right kidney size of 9.4 and a left kidney size of 9.3. the doppler's were unable to be done. 3) renal artery ultrasound done on [**2177-11-26**], revealed no hydronephrosis, patency of the [**last name (lf) 56207**], [**first name3 (lf) **] the doppler's were not done. the right kidney size was 9.6. the left kidney was unable to be estimated for size due to positional factors, however, it looks grossly normal. hospital course: mrs. [**known lastname 5261**] was admitted to the medical intensive care unit. a dermatology consultation was obtained on the evening of the 17th. their assessment that this was represented likely resolving [**doctor last name **]-[**location (un) **] syndrome versus ten and it seems that it is most consistent with ten. she does show significant re-epithelialization. there is no calor, no tenderness, no bullae evident on examination. her eosinophils have dropped from 16% to 12 in the last few days which suggests improvement in her drug hypersensitivity. these and the fact that her prior antibiotics have now been discontinued, suggests that she is resolving from a prior ten. the most likely culprit for this adverse reaction includes lisinopril which was discontinued on [**11-20**], secondary to the development of acute renal failure. other culprits include vancomycin and the cefepime that had been on board since [**8-1**] and were discontinued on [**11-17**]. cefepime was more likely than vancomycin to cause this adverse drug reaction. these antibiotics should be avoided as well as all ace inhibitors. the amlodipine was also recently added after her rash had begun and at this point until we get the actual medical sheets from the rehabilitation facility, we are holding this amlodipine as well. i have spoken to [**hospital3 105**] vent-core unit, [**location (un) 1773**], where the phone number is [**telephone/fax (1) 26091**], and a nurse there was going to fax the start and stop dates of all the medications she was on during her admission there. we have yet to receive that fax. they also recommended checking urine eosinophils which are currently pending, serum eosinophils which did return on her admission as only 3%, however, the morning of transfer have increased to 7%. liver function tests which were normal except for a slightly elevated alkaline phosphatase as well as ggt of 68 and a bun and creatinine that were at 136 and 3.6 on the morning of [**11-26**]. it was also recommended to follow her electrolytes twice a day. her full electrolytes panel the day of transfer was a sodium of 137, potassium 4.7, chloride 103, bicarbonate of 20, bun of 136, creatinine of 3.6, glucose of 208, calcium of 8.6, phosphorus of 3.2, magnesium of 2.4. of note, she also had a white blood cell count of 13.1, hematocrit of 31.3, platelets of 324, with a differential of 78% neutrophils, 1% bands, 7% lymphocytes, 6% monocytes, 7% eosinophils and 1% metas. for her skin we were placing xeroderm patches as well as using bactroban instead of bacitracin to her wounds. the next morning, dermatology obtained two 5 mm skin punch biopsies at the left parasternal line under sterile conditions and were sent to pathology for a diagnosis. an epidermal jelly-roll from epidermis adjacent to fresh erosion also sent in, however, on dermatology fellow's examination, there were no bullae, only erosions. the biopsy sites were sutured with #5 ethilon, two sutures were used at each site. these sutures will need to be removed in approximately two weeks. the above procedure was done by [**first name8 (namepattern2) **] [**last name (namepattern1) 103104**], pager number [**serial number 103105**] [**hospital1 756**]. they also recommended swabbing the neck erosions for cultures which look slightly purulent. other entities on differential diagnoses include staphylococcus skin syndrome, which is possible but probably not likely in this case. we did sent pan-cultures for urine, sputum and blood. we also started her on normal saline fluids at a rate of only 60 cc per hour for now. we were concerned that she might have had some congestive heart failure on her chest x-ray. also, she had a very small intravenous line that was in her finger and we were worried about losing access overnight. her intakes and outputs over an eight hour period overnight was 925 cc in with a urine output of 305 cc per hour. her other work-up for the rash revealed an esr of 20 which is high normal, a tsh and [**doctor first name **] which are pending, and a rheumatoid factor which returned as negative. 2. infectious disease: she was placed on precautions upon admission here for a history of vre in the urine, which was treated with linezolid in [**2177-6-9**]. also with a history of methicillin resistant staphylococcus aureus. all antibiotics were held at this point and her white blood cell count, though, was slightly elevated (she is on prednisone), which was basically normal and she was afebrile. dermatology also suggested getting viral cultures of the punched out lesions of the peri-rectal area that they saw. other infectious disease issues were that the sputum culture gram stain had returned with greater than 25 polys, less than 10 epithelials, however, four plus gram negative rods. her secretions were slightly yellow and thick but as she was afebrile and was in the setting of an acute rash, session: did not start antibiotics. her blood cultures from [**11-25**] were no growth to date so far. 3. renal: the patient is in acute renal failure; likely multi-factorial including recent ace inhibitor, pre-renal causes secondary to a recent increased dose of her lasix, like maybe congestive heart failure, poor oncotic pressure secondary to low albumin and nephrotic range proteinuria. likely ain, especially given increased peripheral eosinophils as well as rash. we decided to send her urine for electrolytes as well as urine for urine urea to check an fe urea. these are pending at the time of this dictation. urine eos were sent. we obtained a renal ultrasound and the results are listed above. she was put in for a cardiac echocardiogram and we decided to rule out myocardial infarction in case myocardial infarction with congestive heart failure had occurred in this case. 4. hypertension: the patient was continued on hydralazine 100 four times a day; clonidine 0.3 three times a day; metoprolol 100 four times a day, labetalol 200 q. six hours; isosorbide 40 three times a day, but the amlodipine was held. her blood pressure had ranged from 143 to 174 systolic overnight. it was decided to initiate a work-up for the secondary causes of her hypertension. it appears that since her kidneys are both of normal size, even though dopplers were unable to be done, that the likelihood of renal artery stenosis was maybe low, however, the test is not definitive. at this time, we are avoiding all ace inhibitors. 5. chronic obstructive pulmonary disease: we are continuing albuterol and atrovent mdi. 6. for diabetes mellitus type 2, we initiated four times a day fingersticks with a regular insulin sliding scale as well as continue her nph insulin at 20 units q. a.m. and 20 units q. p.m. 7. for her anemia with her a very low mcv which is likely secondary to her history of thalassemia trait. a type and screen was sent and her epogen was continued. 8. gastrointestinal: she was continued on colace and p.r.n. bisacodyl. her tube feeds were started. stools were guaiac, however, she had not had a stool. a ggt was checked because of her elevated alkaline phosphatase and this was also found to be elevated at a level of 68. 9. history of pericardial effusion status post window. this is another reason that we wanted to check a transthoracic echocardiogram. she had cardiomegaly on chest x-ray, however, there is no evidence of tamponade on her ekg. 10. fluids, electrolytes and nutrition: most of this was already discussed in the renal section. she was gently hydrated with normal saline 60 cc per hour overnight. the bun and creatinine appear to have maybe remained stable now. she had hypoalbuminemia and nutrition was consulted. we are continuing her calcium carbonate. we are also continuing free water boluses 125 cc per hour q. eight hours per the g-tube. however, if her sodium continues to decrease, then these can be stopped. her electrolytes probably need to be followed twice a day. 11. ventilator: she is currently on assist control 500 x 12, 5 of peep/40% saturation and is saturating well. there is no current reason to change her ventilation settings at this time. 12. prophylaxis: she is on subcutaneous heparin and protonix. 13. tubes, lines and drains: she arrived to the floor with one very small peripheral intravenous in her left finger. a consultation in the a.m. was put in for a stat picc line. the interventional team had assessed her at the bedside and at the time of this dictation, it appears that she will not be undergoing picc placement, but rather will attempt to place some sort of central line. it is unknown exactly how we are going to obtain this access at the point of this dictation. a foley catheter is in place. 14. full code. condition at discharge: fair. discharge status: it was recommended by dermatology that she would benefit from transfer to a burn unit. at this time, she has been accepted to go to the [**hospital6 **] burn unit. of note, it was decided not to start her on intravenous igg at this point. discharge medications: 1. amlodipine 10 mg q. day p.o., recently began on [**11-22**], after the rash had appeared, but has been held today. 2. hydralazine 100 mg four times a day; she has been on this medication for a while. please note that the vent-core sheets report that she began this medicine on [**11-21**], however, this was only a renewal according to dr. [**last name (stitle) **]. 3. lasix 40 mg twice a day. 4. nph 20 units twice a day. 5. h2o 125 cc three times a day. 6. benadryl 25 mg q. eight hours. 7. subcutaneous heparin 5000 twice a day. 8. prednisone 5 mg q. day. 9. protein soy supplement, two scoops in the feeding tube q. eight hours. 10. nepro 3/4 strength tube feeds 35 cc per hour. 11. clonidine 0.3 three times a day. 12. bisacodyl 10 mg q. day p.r.n. 13. regular insulin sliding scale with humulin. 14. lopressor 100 mg four times a day. 15. labetalol 200 mg four times a day. 16. isosorbide dinitrate 40 mg q. eight hours. 17. sublingual nitroglycerin p.r.n. 18. protonix 40 q. day. 19. epogen 40,000 units subcutaneously weekly. 20. brimonidine 0.2% solution, one drop bilaterally q. eight hours. 21. eiazdolamide one drop solution to each eye three times a day. 22. ativan 1 mg q. eight hours. 23. calcium carbonate 500 mg q. eight hours. 24. ipratropium and albuterol mdi four puffs q. four hours p.r.n. discharge diagnoses: 1. acute renal failure. 2. rash most consistent with toxic epidermal necrolysis (ten). 3. severe hypertension on several anti-hypertensive. 4. chronic obstructive pulmonary disease. 5. status post tracheostomy [**7-17**] and peg [**7-28**]. 6. status post pericardial effusion with window placement on [**7-9**]. 7. history of bilateral pleural effusion. 8. history of breast cancer as above. 9. type 2 diabetes mellitus. [**name6 (md) **] [**name8 (md) **], m.d. [**md number(1) 968**] dictated by:[**name8 (md) 210**] medquist36 d: [**2177-11-26**] 13:53 t: [**2177-11-26**] 15:00 job#: [**job number 103106**]",1
13,"patient is a 86y/o m with a pmh of biventricular chf with ef 15%, s/p cabg [**2167**]. presenting on [**1-16**] from osh with complete heart block. s/p permanent pacemaker [**1-16**], now extubated & off all pressor support. ppm set at ddd, rate of 60. has short term memory deficit @ baseline, now exacerbated by sedation drugs/ renal failure. altered mental status (not delirium) assessment: conts to be restless at times, crying out for help. a+ox2, severe short tem memory deficit, constant reminding pt he has a foley. urine remains pink/ red, some clots. action: one time haldol dose given. irrigated foley once. lasix 20mg x1. sons @ bedside to help orientate. speech & swallow consulted. response: fair results from haldol, no attempts to pull line/ tubes. good urine flow from foley, fair results from lasix. passed speech/ swallow-> on nectar thick liquid diet. plan: maintain safety precautions. impaired skin integrity assessment: c/o skin itch on back, red rash noted on l flank/ back. action: lotion applied, ordered for ursodiol. ? benadryl adverse reaction. response: ursodiol d/c d, ordered for sarna lotion. plan: monitor l flank area rash for broken skin. ? drug reaction.",1
14,"86y/o m with a pmh of biventricular chf with ef 15%, presenting on [**1-16**] from osh with chb. s/p permanent pacemaker [**1-16**], now extubated & off all pressor support. ppm set at ddd, rate of 60. has short term memory deficit @ baseline, now exacerbated by sedation drugs/ renal failure. currently day [**1-24**] clindamycin. no clear evidence of pna on cxr, likely pulmonary edema related to severe chf, ? pna given increased sputum production. speech and swallow consult [**1-18**] hematuria assessment: continues to c/o urge to void, attempting to get oob to urinate. urine appearing more red, urine continues to come out of urethral orifice action: foley irrigated. flomax started last night. response: flushed easily, urine noted to come out of urethra. sm clots noted when aspirated back. foley continues to drain adequate amts red urine 30-60cc/hr plan: keep foley in place, irrigate prn, ? urology consult. altered mental status (not delirium) underlying dementia assessment: ms waxes and wanes. calling out for help. restless at times appearing to be r/t urinary discomfort and need to move bowels. oriented [**11-26**]. short term memory loss. asking appropriate questions re: events that led to hospitalization. attempted to get oob mult times during the night. did not sleep most of night, very short naps ~10min action: 1mg haldol iv x1 given at 2330. pt frequently re-oriented, 1:1 supervision until pt calm response: no effect with haldol. no change in ms [**name13 (stitle) 440**]: continue safety precautions, re-orient prn, avoid benzodiazepines & anti-cholinergic meds. hypotension (not shock) assessment: bps via l radial aline 130-140s/50-70s action: half-dose of pt s home dose coreg re-started last night. aline dcd at 0400. response: tolerated coreg plan: continue present management. check csm l hand heart failure (chf), severe biventricular systolic heart failure, acute on chronic assessment: mild non-pitting [**11-25**]+ ble edema. o2 sat 98-100% on 2l nc action: o2 weaned off response: sats wnl, >95% plan: chf management, strict i/os. gentle diuresis with lasix given pre-load dependent. goal neg 500cc/day pleural effusion assessment: action: response: plan: impaired skin integrity assessment: c/o skin itch on back, red rash noted on l flank/ back. action: lotion applied, ordered for ursodiol. ? benadryl adverse reaction. response: ursodiol d/c d, ordered for sarna lotion. plan: monitor l flank area rash for broken skin. ? drug reaction. - sputum - f/u pa/lat cxr cr 3.2 on admission, history of ckd with cr ranging from 2.5-3. cr improved today to 2.7. patient is a",1
15,"chief complaint: 24 hour events: arterial line - stop [**2124-2-4**] 12:00 am made dnr yesterday. no more invasive procedures. family considering cmo. allergies: codeine nausea/vomiting ambien (oral) (zolpidem tartrate) unknown; last dose of antibiotics: vancomycin - [**2124-2-2**] 09:39 pm piperacillin/tazobactam (zosyn) - [**2124-2-3**] 12:41 am infusions: midazolam (versed) - 3 mg/hour fentanyl - 100 mcg/hour norepinephrine - 0.24 mcg/kg/min other icu medications: pantoprazole (protonix) - [**2124-2-3**] 08:04 pm midazolam (versed) - [**2124-2-4**] 12:06 am fentanyl - [**2124-2-4**] 12:07 am heparin sodium (prophylaxis) - [**2124-2-4**] 04:27 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2124-2-4**] 05:42 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.9 c (98.5 tcurrent: 35.8 c (96.5 hr: 70 (65 - 78) bpm bp: 113/65(77) {62/42(47) - 125/74(83)} mmhg rr: 17 (16 - 22) insp/min spo2: 98% heart rhythm: af (atrial fibrillation) cvp: 12 (8 - 17)mmhg total in: 4,163 ml 420 ml po: tf: ivf: 3,963 ml 420 ml blood products: 200 ml total out: 765 ml 170 ml urine: 765 ml 170 ml ng: stool: drains: balance: 3,398 ml 250 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml rr (set): 18 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi deferred: neuromusc block pip: 19 cmh2o plateau: 14 cmh2o compliance: 55.6 cmh2o/ml spo2: 98% abg: ///23/ ve: 8.9 l/min physical examination general: intubated, sedated, opens eyes to sternal rub, not responsive to voice or following commands heent: perrl, pinpoint, anicteric heart: rrr 2/6 systolic murmur best heard at lusb radiating to carotids lungs: coarse bs, diminished in anterior lung fields. abd: +bs hypoactive, nt, mildy distended, soft ext: trace edema b/l with chronic venous stasis changes (l>r), wwp, ue edema bl l>r skin: multiple echymosis. diffuse maculopapular rash over abdomen (stable from yesterday) labs / radiology 110 k/ul 10.1 g/dl 140 mg/dl 1.1 mg/dl 23 meq/l 3.9 meq/l 16 mg/dl 114 meq/l 144 meq/l 29.0 % 7.8 k/ul [image002.jpg] [**2124-2-1**] 03:52 pm [**2124-2-1**] 05:20 pm [**2124-2-1**] 08:39 pm [**2124-2-2**] 04:07 am [**2124-2-2**] 04:46 am [**2124-2-2**] 06:43 am [**2124-2-3**] 01:58 am [**2124-2-3**] 02:15 am [**2124-2-3**] 05:57 pm [**2124-2-4**] 03:24 am wbc 7.1 4.6 5.2 7.8 hct 27.6 26.7 27.1 29.0 plt 131 110 96 110 cr 1.4 1.4 1.0 1.0 1.1 tco2 20 21 23 23 24 glucose 156 175 128 138 140 other labs: pt / ptt / inr:23.5/58.0/2.3, ck / ckmb / troponin-t:468/12/0.06, alt / ast:13/34, alk phos / t bili:32/4.4, differential-neuts:78.8 %, lymph:10.7 %, mono:7.8 %, eos:2.5 %, lactic acid:1.8 mmol/l, albumin:3.7 g/dl, ldh:250 iu/l, ca++:8.7 mg/dl, mg++:1.7 mg/dl, po4:2.3 mg/dl assessment and plan 71 gentleman with alcoholic cirrhosis c/b portal htn, refractory ascites s/p tips [**2119**] found to have occluded tips by u/s in [**12-18**] now s/p tips revision [**2124-1-28**] and portal vein thrombolysis transferred with hypoxia and altered mental status now intubated with persistent hypotension and pressor requirement. . # hypoxemic respiratory failure: hypoxia most likely secondary to aspiration given witnessed aspiration event, decreased o2 sats, new tachypnea, infiltrates on cxr. hap less likely since no fever or elevated wbc. cta negative for pe. other less likely etiologies include hps. finally, his respiratory support is in question at this point pending family meeting to discuss what their goals of care are, and whether extubation is within their wishes. - will d/c vanc/zosyn for hap coverage since no clear indication and may be causing drug reaction - would continue to try and switch to ps and wean as tolerated, not to plan on extubating but to assess pulmonary status - abgs as needed . # mental status changes: timing coincides with tips revision. likely multifactorial secondary to post op delirium, encephalopathy from patent tips and lack of lactulose, underlying cognitive dysfunction, and possible infection. head ct negative for bleed but his ventricles were enlarged with ? communicating hydrocephalus. per discussion with neurology, hydrocephalus unlikely cause of ms changes and is likely chronic. head ct did not show any acute signs of hemorrhage which was concern while on anticoagulation. also concern for sepsis with low uop, borderline low bps. on vanc, zosyn now for asp pna and empiric sbp treatment but will stop since no cx data, no fevers and may be causing adverse reaction with rash. para negative for sbp. ua negative. bld cx ngtd. at this point the only issue not addressed is lactulose for encephalopathy, which is impossible without ngt placement. family meeting will take place today to discuss goals of care and whether ngt is within their wishes. - unable to treat encephalopathy without ngt - on fentanyl and versed for sedation, will titrate to avoid agitation and oversedation - follow up pending cultures - discuss w/family if egd to place ngt is ok . # hypotension: hypotension likely multifactorial secondary to liver disease, ventilator and peep, rv impairment, infection/sepsis. he continues to require pressors and has minimal uop (20-30cc/hr). will add on a second pressor today and continue to monitor. there is question whether a line is [**location (un) **] accurately. - continue levophed, add vasopressin - bolus ns - follow uop - ? [**first name8 (namepattern2) 1619**] [**location (un) **] may be positional, correlate with nbp . # tips revision: had revision [**1-28**]. thrombolysis, angioplasty done with gradient of 6 after procedure was finished. per ir, no need for heparin. briefly on lovenox but discontinued since pt at risk for bleeding. ruq us demonstrates flow but could not assess gradient since agitated. - f/u further ir recs - will likely not undergo reversal given family s wishes to avoid invasive procedures . # portal vein thrombosis: s/p thrombolysis and angioplasty. - no anti-coag for now, has inr>2.0 # pacemaker malfunction/ecg changes: pacemaker not functioning properly per ep secondary to microdislodgement of rv lead per ep. has a history of high grade avb. no revision at this time. - appreciate ep recs - no nodal agents - telemetry # anemia: transfused 1 unit on this admission, hct relatively stable since around baseline and bumped appropriately to i unit. no egd since [**2119**]. theoretically, if tips patent would not need prophylaxis for varices but tips gradient unknown. if hct decreases, will consider checking [**hospital1 7**] hcts -stable . # acute renal failure: baseline cr~1. cr stable to improved, 1 today. to maintain minimal uop requires bolus ns and continued pressors. will monitor at this time and add vasopressing. - holding lasix and spironolactone - ns boluses prn low uop - maintain map 60s to maintaijn perfusion pressure - [**hospital1 7**] albumin . # gout: on colchicine . # le edema: pt had lle edema greater than r concerning for dvt. lle us negative for dvt but limited study due to agitation. lenis negative for dvt . # alcoholic cirrhosis: inactive on transplant list. - hold lasix and spironolactone given arf - appreciate hepatology recs . # thrombocytopenia: plt count stabilized, c/w prior baseline 80s-100s . # dm2: maintain glycemic control with hiss. . # fen/gi unable to feed since cannot place ngt/ogt per family request , replete lytes prn . # ppx - sub q heparin, ppi . # access - piv , rij cvl and left radial a line placed . # code dnr/dni (confirmed with pt). pt's daughter [**name (ni) 4522**] [**numeric identifier 4523**]. cell [**telephone/fax (1) 4524**] . # dispo icu; plan pending family discussion hypotension (not shock) airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) altered mental status (not delirium) alteration in nutrition .h/o alcohol withdrawal (including delirium tremens, dts, seizures) icu care nutrition: glycemic control: lines: 18 gauge - [**2124-2-1**] 11:00 am multi lumen - [**2124-2-1**] 12:49 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: dnr / dni disposition: ------ protected section ------ micu attending addendum i saw and examined the patient, and was physically present with the icu team for the key portions of the services provided. i agree with the note above, including the assessment and plan. i would emphasize and add the following points: 71m etoh cirrhosis, tips [**1-28**] for refractory ascites, progressive encephalopathy, hypoxemia following attempted ngt placement. remains intubated, family refuses further procedures pending meeting today at 1pm. exam notable for tm 98.0 bp 85/40 hr 68af (no capture on pacer spikes) rr 21 with sat 95 on vac 500x18 8 0.4. unresponsive / sedated. diffuse ronchi, irreg s1s2 2/6sm. distended, abdomen, +bs. 3+ edema, rash over trunk. labs notable for wbc 7k, hct 29, k+ 3.9, cr 1.1, na 144. agree with plan to treat aspiration pneumonitis c/b respiratory failure with sedation and vent support, no clear evidence for pneumonia so will hold abx, especially given new drug rash. will lighten sedation and add vpa if needed for bp support. will manage encephalopathy with endoscopic ngt placement, lactulose, rifaximin if family agrees. anemia and cri are stable. care and overall prognosis to be reviewed with son and daughter today at 1pm. based on prior discussion [**2-2**], patient would not want chronic support, but will continue with current level of care in an effort to reverse encephalopathy. mr. [**known lastname **] is dnr. remainder of plan as outlined above. patient is critically ill total time: 50 min ------ protected section addendum entered by:[**name (ni) 453**] [**last name (namepattern1) 775**], md on:[**2124-2-4**] 14:21 ------",1
16,"chief complaint: 24 hour events: arterial line - stop [**2124-2-4**] 12:00 am made dnr yesterday. no more invasive procedures. family considering cmo. allergies: codeine nausea/vomiting ambien (oral) (zolpidem tartrate) unknown; last dose of antibiotics: vancomycin - [**2124-2-2**] 09:39 pm piperacillin/tazobactam (zosyn) - [**2124-2-3**] 12:41 am infusions: midazolam (versed) - 3 mg/hour fentanyl - 100 mcg/hour norepinephrine - 0.24 mcg/kg/min other icu medications: pantoprazole (protonix) - [**2124-2-3**] 08:04 pm midazolam (versed) - [**2124-2-4**] 12:06 am fentanyl - [**2124-2-4**] 12:07 am heparin sodium (prophylaxis) - [**2124-2-4**] 04:27 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2124-2-4**] 05:42 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.9 c (98.5 tcurrent: 35.8 c (96.5 hr: 70 (65 - 78) bpm bp: 113/65(77) {62/42(47) - 125/74(83)} mmhg rr: 17 (16 - 22) insp/min spo2: 98% heart rhythm: af (atrial fibrillation) cvp: 12 (8 - 17)mmhg total in: 4,163 ml 420 ml po: tf: ivf: 3,963 ml 420 ml blood products: 200 ml total out: 765 ml 170 ml urine: 765 ml 170 ml ng: stool: drains: balance: 3,398 ml 250 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml rr (set): 18 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi deferred: neuromusc block pip: 19 cmh2o plateau: 14 cmh2o compliance: 55.6 cmh2o/ml spo2: 98% abg: ///23/ ve: 8.9 l/min physical examination general: intubated, sedated, opens eyes to sternal rub, not responsive to voice or following commands heent: perrl, pinpoint, anicteric heart: rrr 2/6 systolic murmur best heard at lusb radiating to carotids lungs: coarse bs, diminished in anterior lung fields. abd: +bs hypoactive, nt, mildy distended, soft ext: trace edema b/l with chronic venous stasis changes (l>r), wwp, ue edema bl l>r skin: multiple echymosis. diffuse maculopapular rash over abdomen (stable from yesterday) labs / radiology 110 k/ul 10.1 g/dl 140 mg/dl 1.1 mg/dl 23 meq/l 3.9 meq/l 16 mg/dl 114 meq/l 144 meq/l 29.0 % 7.8 k/ul [image002.jpg] [**2124-2-1**] 03:52 pm [**2124-2-1**] 05:20 pm [**2124-2-1**] 08:39 pm [**2124-2-2**] 04:07 am [**2124-2-2**] 04:46 am [**2124-2-2**] 06:43 am [**2124-2-3**] 01:58 am [**2124-2-3**] 02:15 am [**2124-2-3**] 05:57 pm [**2124-2-4**] 03:24 am wbc 7.1 4.6 5.2 7.8 hct 27.6 26.7 27.1 29.0 plt 131 110 96 110 cr 1.4 1.4 1.0 1.0 1.1 tco2 20 21 23 23 24 glucose 156 175 128 138 140 other labs: pt / ptt / inr:23.5/58.0/2.3, ck / ckmb / troponin-t:468/12/0.06, alt / ast:13/34, alk phos / t bili:32/4.4, differential-neuts:78.8 %, lymph:10.7 %, mono:7.8 %, eos:2.5 %, lactic acid:1.8 mmol/l, albumin:3.7 g/dl, ldh:250 iu/l, ca++:8.7 mg/dl, mg++:1.7 mg/dl, po4:2.3 mg/dl assessment and plan 71 gentleman with alcoholic cirrhosis c/b portal htn, refractory ascites s/p tips [**2119**] found to have occluded tips by u/s in [**12-18**] now s/p tips revision [**2124-1-28**] and portal vein thrombolysis transferred with hypoxia and altered mental status now intubated with persistent hypotension and pressor requirement. . # hypoxemic respiratory failure: hypoxia most likely secondary to aspiration given witnessed aspiration event, decreased o2 sats, new tachypnea, infiltrates on cxr. hap less likely since no fever or elevated wbc. cta negative for pe. other less likely etiologies include hps. finally, his respiratory support is in question at this point pending family meeting to discuss what their goals of care are, and whether extubation is within their wishes. - will d/c vanc/zosyn for hap coverage since no clear indication and may be causing drug reaction - would continue to try and switch to ps and wean as tolerated, not to plan on extubating but to assess pulmonary status - abgs as needed . # mental status changes: timing coincides with tips revision. likely multifactorial secondary to post op delirium, encephalopathy from patent tips and lack of lactulose, underlying cognitive dysfunction, and possible infection. head ct negative for bleed but his ventricles were enlarged with ? communicating hydrocephalus. per discussion with neurology, hydrocephalus unlikely cause of ms changes and is likely chronic. head ct did not show any acute signs of hemorrhage which was concern while on anticoagulation. also concern for sepsis with low uop, borderline low bps. on vanc, zosyn now for asp pna and empiric sbp treatment but will stop since no cx data, no fevers and may be causing adverse reaction with rash. para negative for sbp. ua negative. bld cx ngtd. at this point the only issue not addressed is lactulose for encephalopathy, which is impossible without ngt placement. family meeting will take place today to discuss goals of care and whether ngt is within their wishes. - unable to treat encephalopathy without ngt - on fentanyl and versed for sedation, will titrate to avoid agitation and oversedation - follow up blood cx, urine cx, ascetic cx, obtain sputum cx and restart abx if indicated . # hypotension: hypotension likely multifactorial secondary to liver disease, ventilator and peep, rv impairment, infection/sepsis. - continue pressors (currently on levophed) titrate to lower map 60s - would not add second pressor without family discussion regarding management, just bolus for now, accept lower bps - follow uop # tips revision: had revision [**1-28**]. thrombolysis, angioplasty done with gradient of 6 after procedure was finished. per ir, no need for heparin. briefly on lovenox but discontinued since pt at risk for bleeding. ruq us demonstrates flow but could not assess gradient since agitated. - f/u further ir recs - consider reversing tips due to gross encephalopathy but pt s family does not want further invasive procedures . # portal vein thrombosis: s/p thrombolysis and angioplasty. - no anti-coag for now, has inr>2.0 # pacemaker malfunction/ecg changes: pacemaker not functioning properly per ep secondary to microdislodgement of rv lead per ep. has a history of high grade avb. if recovers, will need lead revision. - appreciate ep recs - no nodal agents - telemetry # anemia: transfused 1 unit on this admission, hct relatively stable since around baseline and bumped appropriately to i unit. no egd since [**2119**]. theoretically, if tips patent would not need prophylaxis for varices but tips gradient unknown. if hct decreases, will consider checking [**hospital1 7**] hcts . # acute renal failure: baseline cr~1. cr stable to improved, 1 today. has had good uop last 24 hours, requiring boluses x 2 for low uop and bp but seems to respond well to this. - holding lasix and spironolactone - ns boluses prn low uop - maintain map 60s to maintaijn perfusion pressure - [**hospital1 7**] albumin . # gout: on colchicine . # le edema: pt had lle edema greater than r concerning for dvt. lle us negative for dvt but limited study due to agitation. lenis negative for dvt . # alcoholic cirrhosis: inactive on transplant list. - hold lasix and spironolactone given arf - appreciate hepatology recs . # thrombocytopenia: plt count stabilized, c/w prior baseline 80s-100s . # dm2: maintain glycemic control with hiss. . # fen/gi unable to feed since cannot place ngt/ogt per pt request , replete lytes prn . # ppx - sub q heparin, ppi . # access - piv , rij cvl and left radial a line placed . # code - full (confirmed with pt). pt's daughter [**name (ni) 4522**] [**numeric identifier 4523**]. cell [**telephone/fax (1) 4524**] . # dispo - pending improvement in mental status hypotension (not shock) airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) altered mental status (not delirium) alteration in nutrition .h/o alcohol withdrawal (including delirium tremens, dts, seizures) icu care nutrition: glycemic control: lines: 18 gauge - [**2124-2-1**] 11:00 am multi lumen - [**2124-2-1**] 12:49 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: dnr / dni disposition:",1
17,"chief complaint: 24 hour events: arterial line - stop [**2124-2-4**] 12:00 am made dnr yesterday. no more invasive procedures. family considering cmo. allergies: codeine nausea/vomiting ambien (oral) (zolpidem tartrate) unknown; last dose of antibiotics: vancomycin - [**2124-2-2**] 09:39 pm piperacillin/tazobactam (zosyn) - [**2124-2-3**] 12:41 am infusions: midazolam (versed) - 3 mg/hour fentanyl - 100 mcg/hour norepinephrine - 0.24 mcg/kg/min other icu medications: pantoprazole (protonix) - [**2124-2-3**] 08:04 pm midazolam (versed) - [**2124-2-4**] 12:06 am fentanyl - [**2124-2-4**] 12:07 am heparin sodium (prophylaxis) - [**2124-2-4**] 04:27 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2124-2-4**] 05:42 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.9 c (98.5 tcurrent: 35.8 c (96.5 hr: 70 (65 - 78) bpm bp: 113/65(77) {62/42(47) - 125/74(83)} mmhg rr: 17 (16 - 22) insp/min spo2: 98% heart rhythm: af (atrial fibrillation) cvp: 12 (8 - 17)mmhg total in: 4,163 ml 420 ml po: tf: ivf: 3,963 ml 420 ml blood products: 200 ml total out: 765 ml 170 ml urine: 765 ml 170 ml ng: stool: drains: balance: 3,398 ml 250 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml rr (set): 18 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi deferred: neuromusc block pip: 19 cmh2o plateau: 14 cmh2o compliance: 55.6 cmh2o/ml spo2: 98% abg: ///23/ ve: 8.9 l/min physical examination general: intubated, sedated, opens eyes to sternal rub, not responsive to voice or following commands heent: perrl, pinpoint, anicteric heart: rrr 2/6 systolic murmur best heard at lusb radiating to carotids lungs: coarse bs, diminished in anterior lung fields. abd: +bs hypoactive, nt, mildy distended, soft ext: trace edema b/l with chronic venous stasis changes (l>r), wwp, ue edema bl l>r skin: multiple echymosis. diffuse maculopapular rash over abdomen (stable from yesterday) labs / radiology 110 k/ul 10.1 g/dl 140 mg/dl 1.1 mg/dl 23 meq/l 3.9 meq/l 16 mg/dl 114 meq/l 144 meq/l 29.0 % 7.8 k/ul [image002.jpg] [**2124-2-1**] 03:52 pm [**2124-2-1**] 05:20 pm [**2124-2-1**] 08:39 pm [**2124-2-2**] 04:07 am [**2124-2-2**] 04:46 am [**2124-2-2**] 06:43 am [**2124-2-3**] 01:58 am [**2124-2-3**] 02:15 am [**2124-2-3**] 05:57 pm [**2124-2-4**] 03:24 am wbc 7.1 4.6 5.2 7.8 hct 27.6 26.7 27.1 29.0 plt 131 110 96 110 cr 1.4 1.4 1.0 1.0 1.1 tco2 20 21 23 23 24 glucose 156 175 128 138 140 other labs: pt / ptt / inr:23.5/58.0/2.3, ck / ckmb / troponin-t:468/12/0.06, alt / ast:13/34, alk phos / t bili:32/4.4, differential-neuts:78.8 %, lymph:10.7 %, mono:7.8 %, eos:2.5 %, lactic acid:1.8 mmol/l, albumin:3.7 g/dl, ldh:250 iu/l, ca++:8.7 mg/dl, mg++:1.7 mg/dl, po4:2.3 mg/dl assessment and plan 71 gentleman with alcoholic cirrhosis c/b portal htn, refractory ascites s/p tips [**2119**] found to have occluded tips by u/s in [**12-18**] now s/p tips revision [**2124-1-28**] and portal vein thrombolysis transferred with hypoxia and altered mental status now intubated with persistent hypotension and pressor requirement. . # hypoxemic respiratory failure: hypoxia most likely secondary to aspiration given witnessed aspiration event, decreased o2 sats, new tachypnea, infiltrates on cxr. hap less likely since no fever or elevated wbc. cta negative for pe. other less likely etiologies include hps. finally, his respiratory support is in question at this point pending family meeting to discuss what their goals of care are, and whether extubation is within their wishes. - will d/c vanc/zosyn for hap coverage since no clear indication and may be causing drug reaction - would continue to try and switch to ps and wean as tolerated, not to plan on extubating but to assess pulmonary status - abgs as needed . # mental status changes: timing coincides with tips revision. likely multifactorial secondary to post op delirium, encephalopathy from patent tips and lack of lactulose, underlying cognitive dysfunction, and possible infection. head ct negative for bleed but his ventricles were enlarged with ? communicating hydrocephalus. per discussion with neurology, hydrocephalus unlikely cause of ms changes and is likely chronic. head ct did not show any acute signs of hemorrhage which was concern while on anticoagulation. also concern for sepsis with low uop, borderline low bps. on vanc, zosyn now for asp pna and empiric sbp treatment but will stop since no cx data, no fevers and may be causing adverse reaction with rash. para negative for sbp. ua negative. bld cx ngtd. at this point the only issue not addressed is lactulose for encephalopathy, which is impossible without ngt placement. family meeting will take place today to discuss goals of care and whether ngt is within their wishes. - unable to treat encephalopathy without ngt - on fentanyl and versed for sedation, will titrate to avoid agitation and oversedation - follow up pending cultures - discuss w/family if egd to place ngt is ok . # hypotension: hypotension likely multifactorial secondary to liver disease, ventilator and peep, rv impairment, infection/sepsis. he continues to require pressors and has minimal uop (20-30cc/hr). will add on a second pressor today and continue to monitor. there is question whether a line is [**location (un) **] accurately. - continue levophed, add vasopressin - bolus ns - follow uop - ? [**first name8 (namepattern2) 1619**] [**location (un) **] may be positional, correlate with nbp . # tips revision: had revision [**1-28**]. thrombolysis, angioplasty done with gradient of 6 after procedure was finished. per ir, no need for heparin. briefly on lovenox but discontinued since pt at risk for bleeding. ruq us demonstrates flow but could not assess gradient since agitated. - f/u further ir recs - will likely not undergo reversal given family s wishes to avoid invasive procedures . # portal vein thrombosis: s/p thrombolysis and angioplasty. - no anti-coag for now, has inr>2.0 # pacemaker malfunction/ecg changes: pacemaker not functioning properly per ep secondary to microdislodgement of rv lead per ep. has a history of high grade avb. no revision at this time. - appreciate ep recs - no nodal agents - telemetry # anemia: transfused 1 unit on this admission, hct relatively stable since around baseline and bumped appropriately to i unit. no egd since [**2119**]. theoretically, if tips patent would not need prophylaxis for varices but tips gradient unknown. if hct decreases, will consider checking [**hospital1 7**] hcts -stable . # acute renal failure: baseline cr~1. cr stable to improved, 1 today. to maintain minimal uop requires bolus ns and continued pressors. will monitor at this time and add vasopressing. - holding lasix and spironolactone - ns boluses prn low uop - maintain map 60s to maintaijn perfusion pressure - [**hospital1 7**] albumin . # gout: on colchicine . # le edema: pt had lle edema greater than r concerning for dvt. lle us negative for dvt but limited study due to agitation. lenis negative for dvt . # alcoholic cirrhosis: inactive on transplant list. - hold lasix and spironolactone given arf - appreciate hepatology recs . # thrombocytopenia: plt count stabilized, c/w prior baseline 80s-100s . # dm2: maintain glycemic control with hiss. . # fen/gi unable to feed since cannot place ngt/ogt per family request , replete lytes prn . # ppx - sub q heparin, ppi . # access - piv , rij cvl and left radial a line placed . # code dnr/dni (confirmed with pt). pt's daughter [**name (ni) 4522**] [**numeric identifier 4523**]. cell [**telephone/fax (1) 4524**] . # dispo icu; plan pending family discussion hypotension (not shock) airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) altered mental status (not delirium) alteration in nutrition .h/o alcohol withdrawal (including delirium tremens, dts, seizures) icu care nutrition: glycemic control: lines: 18 gauge - [**2124-2-1**] 11:00 am multi lumen - [**2124-2-1**] 12:49 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: dnr / dni disposition:",1
18,"chief complaint: 24 hour events: invasive ventilation - stop [**2124-2-4**] 03:30 pm made cmo by family allergies: codeine nausea/vomiting ambien (oral) (zolpidem tartrate) unknown; last dose of antibiotics: vancomycin - [**2124-2-2**] 09:39 pm piperacillin/tazobactam (zosyn) - [**2124-2-3**] 12:41 am infusions: fentanyl - 175 mcg/hour other icu medications: pantoprazole (protonix) - [**2124-2-4**] 08:32 am midazolam (versed) - [**2124-2-4**] 03:30 pm fentanyl - [**2124-2-4**] 06:17 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2124-2-5**] 05:58 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.5 c (97.7 tcurrent: 35.9 c (96.7 hr: 69 (67 - 78) bpm bp: 57/28(34) {51/23(30) - 112/43,100(85)} mmhg rr: 10 (0 - 21) insp/min spo2: 94% heart rhythm: af (atrial fibrillation) cvp: 11 (10 - 21)mmhg total in: 1,947 ml 164 ml po: tf: ivf: 1,947 ml 164 ml blood products: total out: 445 ml 25 ml urine: 445 ml 25 ml ng: stool: drains: balance: 1,502 ml 139 ml respiratory support o2 delivery device: nasal cannula ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml rr (set): 18 peep: 5 cmh2o fio2: 40% pip: 22 cmh2o plateau: 14 cmh2o spo2: 94% abg: //// ve: 9.5 l/min physical examination peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) skin: not assessed neurologic: responds to: not assessed, movement: not assessed, tone: not assessed labs / radiology 110 k/ul 10.1 g/dl 140 mg/dl 1.1 mg/dl 23 meq/l 3.9 meq/l 16 mg/dl 114 meq/l 144 meq/l 29.0 % 7.8 k/ul [image002.jpg] [**2124-2-1**] 03:52 pm [**2124-2-1**] 05:20 pm [**2124-2-1**] 08:39 pm [**2124-2-2**] 04:07 am [**2124-2-2**] 04:46 am [**2124-2-2**] 06:43 am [**2124-2-3**] 01:58 am [**2124-2-3**] 02:15 am [**2124-2-3**] 05:57 pm [**2124-2-4**] 03:24 am wbc 7.1 4.6 5.2 7.8 hct 27.6 26.7 27.1 29.0 plt 131 110 96 110 cr 1.4 1.4 1.0 1.0 1.1 tco2 20 21 23 23 24 glucose 156 175 128 138 140 other labs: pt / ptt / inr:23.5/58.0/2.3, ck / ckmb / troponin-t:468/12/0.06, alt / ast:13/34, alk phos / t bili:32/4.4, differential-neuts:78.8 %, lymph:10.7 %, mono:7.8 %, eos:2.5 %, lactic acid:1.8 mmol/l, albumin:3.7 g/dl, ldh:250 iu/l, ca++:8.7 mg/dl, mg++:1.7 mg/dl, po4:2.3 mg/dl assessment and plan 71 gentleman with alcoholic cirrhosis c/b portal htn, refractory ascites s/p tips [**2119**] found to have occluded tips by u/s in [**12-18**] now s/p tips revision [**2124-1-28**] and portal vein thrombolysis transferred with hypoxia and altered mental status now intubated with persistent hypotension and pressor requirement. . # hypoxemic respiratory failure: hypoxia most likely secondary to aspiration given witnessed aspiration event, decreased o2 sats, new tachypnea, infiltrates on cxr. hap less likely since no fever or elevated wbc. cta negative for pe. other less likely etiologies include hps. finally, his respiratory support is in question at this point pending family meeting to discuss what their goals of care are, and whether extubation is within their wishes. - will d/c vanc/zosyn for hap coverage since no clear indication and may be causing drug reaction - would continue to try and switch to ps and wean as tolerated, not to plan on extubating but to assess pulmonary status - abgs as needed . # mental status changes: timing coincides with tips revision. likely multifactorial secondary to post op delirium, encephalopathy from patent tips and lack of lactulose, underlying cognitive dysfunction, and possible infection. head ct negative for bleed but his ventricles were enlarged with ? communicating hydrocephalus. per discussion with neurology, hydrocephalus unlikely cause of ms changes and is likely chronic. head ct did not show any acute signs of hemorrhage which was concern while on anticoagulation. also concern for sepsis with low uop, borderline low bps. on vanc, zosyn now for asp pna and empiric sbp treatment but will stop since no cx data, no fevers and may be causing adverse reaction with rash. para negative for sbp. ua negative. bld cx ngtd. at this point the only issue not addressed is lactulose for encephalopathy, which is impossible without ngt placement. family meeting will take place today to discuss goals of care and whether ngt is within their wishes. - unable to treat encephalopathy without ngt - on fentanyl and versed for sedation, will titrate to avoid agitation and oversedation - follow up pending cultures - discuss w/family if egd to place ngt is ok . # hypotension: hypotension likely multifactorial secondary to liver disease, ventilator and peep, rv impairment, infection/sepsis. he continues to require pressors and has minimal uop (20-30cc/hr). will add on a second pressor today and continue to monitor. there is question whether a line is [**location (un) **] accurately. - continue levophed, add vasopressin - bolus ns - follow uop - ? [**first name8 (namepattern2) 1619**] [**location (un) **] may be positional, correlate with nbp . # tips revision: had revision [**1-28**]. thrombolysis, angioplasty done with gradient of 6 after procedure was finished. per ir, no need for heparin. briefly on lovenox but discontinued since pt at risk for bleeding. ruq us demonstrates flow but could not assess gradient since agitated. - f/u further ir recs - will likely not undergo reversal given family s wishes to avoid invasive procedures . # portal vein thrombosis: s/p thrombolysis and angioplasty. - no anti-coag for now, has inr>2.0 # pacemaker malfunction/ecg changes: pacemaker not functioning properly per ep secondary to microdislodgement of rv lead per ep. has a history of high grade avb. no revision at this time. - appreciate ep recs - no nodal agents - telemetry # anemia: transfused 1 unit on this admission, hct relatively stable since around baseline and bumped appropriately to i unit. no egd since [**2119**]. theoretically, if tips patent would not need prophylaxis for varices but tips gradient unknown. if hct decreases, will consider checking [**hospital1 7**] hcts -stable . # acute renal failure: baseline cr~1. cr stable to improved, 1 today. to maintain minimal uop requires bolus ns and continued pressors. will monitor at this time and add vasopressing. - holding lasix and spironolactone - ns boluses prn low uop - maintain map 60s to maintaijn perfusion pressure - [**hospital1 7**] albumin . # gout: on colchicine . # le edema: pt had lle edema greater than r concerning for dvt. lle us negative for dvt but limited study due to agitation. lenis negative for dvt . # alcoholic cirrhosis: inactive on transplant list. - hold lasix and spironolactone given arf - appreciate hepatology recs . # thrombocytopenia: plt count stabilized, c/w prior baseline 80s-100s . # dm2: maintain glycemic control with hiss. . # fen/gi unable to feed since cannot place ngt/ogt per family request , replete lytes prn . # ppx - sub q heparin, ppi . # access - piv , rij cvl and left radial a line placed . # code dnr/dni (confirmed with pt). pt's daughter [**name (ni) 4522**] [**numeric identifier 4523**]. cell [**telephone/fax (1) 4524**] . # dispo icu; plan pending family discussion comfort care (cmo, comfort measures) rash renal failure, acute (acute renal failure, arf) impaired skin integrity .h/o diabetes mellitus (dm), type ii hypotension (not shock) airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) altered mental status (not delirium) alteration in nutrition .h/o alcohol withdrawal (including delirium tremens, dts, seizures) icu care nutrition: glycemic control: lines: multi lumen - [**2124-2-1**] 12:49 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: comfort measures only disposition:",1
19,"chief complaint: 24 hour events: pt made dnr per family and requested no further invasive procedures or escalation of care did not have ngt placed secondary to family request decreased peep to 5 cta neg for pe lenis neg ue/le b/l sbp 70s with 15cc/hr levophed around 2 am. bolused 500cc, with uop 40 cc/hr sbp 80-90s, bolused 500cc again this am developed new rash on abdomen allergies: codeine nausea/vomiting ambien (oral) (zolpidem tartrate) unknown; last dose of antibiotics: vancomycin - [**2124-2-2**] 09:39 pm piperacillin/tazobactam (zosyn) - [**2124-2-3**] 12:41 am infusions: midazolam (versed) - 3 mg/hour fentanyl - 100 mcg/hour norepinephrine - 0.23 mcg/kg/min other icu medications: fentanyl - [**2124-2-2**] 01:33 pm midazolam (versed) - [**2124-2-2**] 05:10 pm heparin sodium (prophylaxis) - [**2124-2-2**] 08:00 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2124-2-3**] 04:42 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.2 c (97.2 tcurrent: 35.6 c (96.1 hr: 60 (57 - 74) bpm bp: 96/48(66) {85/48(62) - 112/91(279)} mmhg rr: 18 (14 - 22) insp/min spo2: 99% heart rhythm: af (atrial fibrillation) cvp: 17 (14 - 21)mmhg total in: 4,579 ml 1,483 ml po: tf: ivf: 4,479 ml 1,383 ml blood products: 100 ml 100 ml total out: 975 ml 165 ml urine: 850 ml 165 ml ng: stool: drains: 125 ml balance: 3,604 ml 1,318 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml rr (set): 18 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi deferred: agitated pip: 24 cmh2o plateau: 17 cmh2o compliance: 41.7 cmh2o/ml spo2: 99% abg: 7.36/40/95.[**numeric identifier 143**]/23/-2 ve: 9.2 l/min pao2 / fio2: 240 physical examination general: intubated, sedated, opens eyes to sternal rub, not responsive to voice or following commands, mae heent: perrl, pinpoint, op with dried blood, no e/o recent bleed neck: unable to appreciate any elevated jvp heart: rrr 2/6 systolic murmur best heard at lusb radiating to carotids lungs: coarse bs, diminished in anterior lung fields. abd: +bs, slightly hypoactive, nt, mildy distended, soft ext: trace edema b/l with chronic venous stasis changes (l>r), wwp, ue edema bl l>r neuro: limited by his mental status, spontaneously moves all 4 extremities,responsive to sternal rub . skin: multiple echymosis cta: no pe. cardiomegaly. coronary disease. small b/l effusions and atelectasis. l common carotid doesn t opacify, enlarged nodes in axilla, mediastinum, hilar. moderate ascites and cirrhosis labs / radiology 96 k/ul 9.5 g/dl 128 mg/dl 1.0 mg/dl 23 meq/l 3.3 meq/l 16 mg/dl 112 meq/l 143 meq/l 27.1 % 5.2 k/ul [image002.jpg] [**2124-2-1**] 03:02 pm [**2124-2-1**] 03:06 pm [**2124-2-1**] 03:52 pm [**2124-2-1**] 05:20 pm [**2124-2-1**] 08:39 pm [**2124-2-2**] 04:07 am [**2124-2-2**] 04:46 am [**2124-2-2**] 06:43 am [**2124-2-3**] 01:58 am [**2124-2-3**] 02:15 am wbc 7.1 4.6 5.2 hct 26.4 27.6 26.7 27.1 plt 131 110 96 cr 1.4 1.4 1.4 1.0 tco2 20 20 21 23 23 24 glucose 156 156 175 128 other labs: pt / ptt / inr:23.5/58.0/2.3, ck / ckmb / troponin-t:468/12/0.06, alt / ast:13/34, alk phos / t bili:32/4.4, differential-neuts:78.8 %, lymph:10.7 %, mono:7.8 %, eos:2.5 %, lactic acid:1.8 mmol/l, albumin:3.7 g/dl, ldh:250 iu/l, ca++:8.7 mg/dl, mg++:1.8 mg/dl, po4:2.5 mg/dl assessment and plan 71 gentleman with alcoholic cirrhosis c/b portal htn, refractory ascites s/p tips [**2119**] found to have occluded tips by u/s in [**12-18**] now s/p tips revision [**2124-1-28**] and portal vein thrombolysis transferred with hypoxia and altered mental status now intubated with persistent hypotension and pressor requirement. . # hypoxemic respiratory failure: hypoxia most likely secondary to aspiration given witnessed aspiration event, decreased o2 sats, new tachypnea, infiltrates on cxr. hap less likely since no fever or elevated wbc. also concerning for pe given rv dilation and hypokinesis but none seen on cta. other less likely etiologies include hps. - will d/c vanc/zosyn for hap coverage since no clear indication and may be causing drug reaction - would continue current vent settings for now - serial abgs to trend lactate, monitor oxygenation and ventilation - cta today to eval for pe . # mental status changes: timing coincides with tips revision. likely multifactorial secondary to post op delirium, encephalopathy from patent tips and lack of lactulose, underlying cognitive dysfunction, and possible infection. head ct negative for bleed but his ventricles were enlarged with ? communicating hydrocephalus. per discussion with neurology, hydrocephalus unlikely cause of ms changes and is likely chronic. head ct did not show any acute signs of hemorrhage which was concern while on anticoagulation. also concern for sepsis with low uop, borderline low bps. on vanc, zosyn now for asp pna and empiric sbp treatment but will stop since no cx data, no fevers and may be causing adverse reaction with rash. para negative for sbp. ua negative. bld cx ngtd. also on the differential will be alcohol withdrawal but less likely given time course, has been in hospital since [**1-21**] and only received ativan after tips on [**1-28**]. - unable to treat encephalopathy without ngt - on fentanyl and versed for sedation, will titrate to avoid agitation and oversedation - follow up blood cx, urine cx, ascetic cx, obtain sputum cx and restart abx if indicated - could consider occluding tips if unable to reverse ms changes but family not interested in invasive procedures . # hypotension: hypotension likely multifactorial secondary to liver disease, ventilator and peep, rv impairment, infection/sepsis. - continue pressors (currently on levophed) titrate to lower map 60s - would not add second pressor without family discussion regarding management, just bolus for now, accept lower bps - follow uop # tips revision: had revision [**1-28**]. thrombolysis, angioplasty done with gradient of 6 after procedure was finished. per ir, no need for heparin. briefly on lovenox but discontinued since pt at risk for bleeding. ruq us demonstrates flow but could not assess gradient since agitated. - f/u further ir recs - consider reversing tips due to gross encephalopathy but pt s family does not want further invasive procedures . # portal vein thrombosis: s/p thrombolysis and angioplasty. - no anti-coag for now, has inr>2.0 # pacemaker malfunction/ecg changes: pacemaker not functioning properly per ep secondary to microdislodgement of rv lead per ep. has a history of high grade avb. if recovers, will need lead revision. - appreciate ep recs - no nodal agents - telemetry # anemia: transfused 1 unit on this admission, hct relatively stable since around baseline and bumped appropriately to i unit. no egd since [**2119**]. theoretically, if tips patent would not need prophylaxis for varices but tips gradient unknown. if hct decreases, will consider checking [**hospital1 7**] hcts . # acute renal failure: baseline cr~1. cr stable to improved, 1 today. has had good uop last 24 hours, requiring boluses x 2 for low uop and bp but seems to respond well to this. - holding lasix and spironolactone - ns boluses prn low uop - maintain map 60s to maintaijn perfusion pressure - [**hospital1 7**] albumin . # gout: on colchicine . # le edema: pt had lle edema greater than r concerning for dvt. lle us negative for dvt but limited study due to agitation. lenis negative for dvt . # alcoholic cirrhosis: inactive on transplant list. - hold lasix and spironolactone given arf - appreciate hepatology recs . # thrombocytopenia: plt count stabilized, c/w prior baseline 80s-100s . # dm2: maintain glycemic control with hiss. . # fen/gi unable to feed since cannot place ngt/ogt per pt request , replete lytes prn . # ppx - sub q heparin, ppi . # access - piv , rij cvl and left radial a line placed . # code - full (confirmed with pt). pt's daughter [**name (ni) 4522**] [**numeric identifier 4523**]. cell [**telephone/fax (1) 4524**] . # dispo - pending improvement in mental status hypotension (not shock) airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) altered mental status (not delirium) alteration in nutrition .h/o alcohol withdrawal (including delirium tremens, dts, seizures) icu care nutrition: glycemic control: lines: 18 gauge - [**2124-2-1**] 11:00 am multi lumen - [**2124-2-1**] 12:49 pm arterial line - [**2124-2-1**] 12:50 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: dnr / dni disposition:",1
20,"chief complaint: 24 hour events: pt made dnr per family and requested no further invasive procedures or escalation of care did not have ngt placed secondary to family request decreased peep to 5 cta neg for pe lenis neg ue/le b/l sbp 70s with 15cc/hr levophed around 2 am. bolused 500cc, with uop 40 cc/hr sbp 80-90s, bolused 500cc again this am developed new rash on abdomen allergies: codeine nausea/vomiting ambien (oral) (zolpidem tartrate) unknown; last dose of antibiotics: vancomycin - [**2124-2-2**] 09:39 pm piperacillin/tazobactam (zosyn) - [**2124-2-3**] 12:41 am infusions: midazolam (versed) - 3 mg/hour fentanyl - 100 mcg/hour norepinephrine - 0.23 mcg/kg/min other icu medications: fentanyl - [**2124-2-2**] 01:33 pm midazolam (versed) - [**2124-2-2**] 05:10 pm heparin sodium (prophylaxis) - [**2124-2-2**] 08:00 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2124-2-3**] 04:42 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.2 c (97.2 tcurrent: 35.6 c (96.1 hr: 60 (57 - 74) bpm bp: 96/48(66) {85/48(62) - 112/91(279)} mmhg rr: 18 (14 - 22) insp/min spo2: 99% heart rhythm: af (atrial fibrillation) cvp: 17 (14 - 21)mmhg total in: 4,579 ml 1,483 ml po: tf: ivf: 4,479 ml 1,383 ml blood products: 100 ml 100 ml total out: 975 ml 165 ml urine: 850 ml 165 ml ng: stool: drains: 125 ml balance: 3,604 ml 1,318 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml rr (set): 18 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi deferred: agitated pip: 24 cmh2o plateau: 17 cmh2o compliance: 41.7 cmh2o/ml spo2: 99% abg: 7.36/40/95.[**numeric identifier 143**]/23/-2 ve: 9.2 l/min pao2 / fio2: 240 physical examination general: intubated, sedated, opens eyes to sternal rub, not responsive to voice or following commands, mae heent: perrl, pinpoint, op with dried blood, no e/o recent bleed neck: unable to appreciate any elevated jvp heart: rrr 2/6 systolic murmur best heard at lusb radiating to carotids lungs: coarse bs, diminished in anterior lung fields. abd: +bs, slightly hypoactive, nt, mildy distended, soft ext: trace edema b/l with chronic venous stasis changes (l>r), wwp, ue edema bl l>r neuro: limited by his mental status, spontaneously moves all 4 extremities,responsive to sternal rub . skin: multiple echymosis cta: no pe. cardiomegaly. coronary disease. small b/l effusions and atelectasis. l common carotid doesn t opacify, enlarged nodes in axilla, mediastinum, hilar. moderate ascites and cirrhosis labs / radiology 96 k/ul 9.5 g/dl 128 mg/dl 1.0 mg/dl 23 meq/l 3.3 meq/l 16 mg/dl 112 meq/l 143 meq/l 27.1 % 5.2 k/ul [image002.jpg] [**2124-2-1**] 03:02 pm [**2124-2-1**] 03:06 pm [**2124-2-1**] 03:52 pm [**2124-2-1**] 05:20 pm [**2124-2-1**] 08:39 pm [**2124-2-2**] 04:07 am [**2124-2-2**] 04:46 am [**2124-2-2**] 06:43 am [**2124-2-3**] 01:58 am [**2124-2-3**] 02:15 am wbc 7.1 4.6 5.2 hct 26.4 27.6 26.7 27.1 plt 131 110 96 cr 1.4 1.4 1.4 1.0 tco2 20 20 21 23 23 24 glucose 156 156 175 128 other labs: pt / ptt / inr:23.5/58.0/2.3, ck / ckmb / troponin-t:468/12/0.06, alt / ast:13/34, alk phos / t bili:32/4.4, differential-neuts:78.8 %, lymph:10.7 %, mono:7.8 %, eos:2.5 %, lactic acid:1.8 mmol/l, albumin:3.7 g/dl, ldh:250 iu/l, ca++:8.7 mg/dl, mg++:1.8 mg/dl, po4:2.5 mg/dl assessment and plan 71 gentleman with alcoholic cirrhosis c/b portal htn, refractory ascites s/p tips [**2119**] found to have occluded tips by u/s in [**12-18**] now s/p tips revision [**2124-1-28**] and portal vein thrombolysis transferred with hypoxia and altered mental status now intubated with persistent hypotension and pressor requirement. . # hypoxemic respiratory failure: hypoxia most likely secondary to aspiration given witnessed aspiration event, decreased o2 sats, new tachypnea, infiltrates on cxr. hap less likely since no fever or elevated wbc. also concerning for pe given rv dilation and hypokinesis but none seen on cta. other less likely etiologies include hps. - will d/c vanc/zosyn for hap coverage since no clear indication and may be causing drug reaction - would continue current vent settings for now - serial abgs to trend lactate, monitor oxygenation and ventilation - cta today to eval for pe . # mental status changes: timing coincides with tips revision. likely multifactorial secondary to post op delirium, encephalopathy from patent tips and lack of lactulose, underlying cognitive dysfunction, and possible infection. head ct negative for bleed but his ventricles were enlarged with ? communicating hydrocephalus. per discussion with neurology, hydrocephalus unlikely cause of ms changes and is likely chronic. head ct did not show any acute signs of hemorrhage which was concern while on anticoagulation. also concern for sepsis with low uop, borderline low bps. on vanc, zosyn now for asp pna and empiric sbp treatment but will stop since no cx data, no fevers and may be causing adverse reaction with rash. para negative for sbp. ua negative. bld cx ngtd. also on the differential will be alcohol withdrawal but less likely given time course, has been in hospital since [**1-21**] and only received ativan after tips on [**1-28**]. - unable to treat encephalopathy without ngt - on fentanyl and versed for sedation, will titrate to avoid agitation and oversedation - follow up blood cx, urine cx, ascetic cx, obtain sputum cx and restart abx if indicated - could consider occluding tips if unable to reverse ms changes but family not interested in invasive procedures . # hypotension: hypotension likely multifactorial secondary to liver disease, ventilator and peep, rv impairment, infection/sepsis. - continue pressors (currently on levophed) titrate to lower map 60s - would not add second pressor without family discussion regarding management, just bolus for now, accept lower bps - follow uop # tips revision: had revision [**1-28**]. thrombolysis, angioplasty done with gradient of 6 after procedure was finished. per ir, no need for heparin. briefly on lovenox but discontinued since pt at risk for bleeding. ruq us demonstrates flow but could not assess gradient since agitated. - f/u further ir recs - consider reversing tips due to gross encephalopathy but pt s family does not want further invasive procedures . # portal vein thrombosis: s/p thrombolysis and angioplasty. - no anti-coag for now, has inr>2.0 # pacemaker malfunction/ecg changes: pacemaker not functioning properly per ep secondary to microdislodgement of rv lead per ep. has a history of high grade avb. if recovers, will need lead revision. - appreciate ep recs - no nodal agents - telemetry # anemia: transfused 1 unit on this admission, hct relatively stable since around baseline and bumped appropriately to i unit. no egd since [**2119**]. theoretically, if tips patent would not need prophylaxis for varices but tips gradient unknown. if hct decreases, will consider checking [**hospital1 7**] hcts . # acute renal failure: baseline cr~1. cr stable to improved, 1 today. has had good uop last 24 hours, requiring boluses x 2 for low uop and bp but seems to respond well to this. - holding lasix and spironolactone - ns boluses prn low uop - maintain map 60s to maintaijn perfusion pressure - [**hospital1 7**] albumin . # gout: on colchicine . # le edema: pt had lle edema greater than r concerning for dvt. lle us negative for dvt but limited study due to agitation. lenis negative for dvt . # alcoholic cirrhosis: inactive on transplant list. - hold lasix and spironolactone given arf - appreciate hepatology recs . # thrombocytopenia: plt count stabilized, c/w prior baseline 80s-100s . # dm2: maintain glycemic control with hiss. . # fen/gi unable to feed since cannot place ngt/ogt per pt request , replete lytes prn . # ppx - sub q heparin, ppi . # access - piv , rij cvl and left radial a line placed . # code - full (confirmed with pt). pt's daughter [**name (ni) 4522**] [**numeric identifier 4523**]. cell [**telephone/fax (1) 4524**] . # dispo - pending improvement in mental status hypotension (not shock) airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) altered mental status (not delirium) alteration in nutrition .h/o alcohol withdrawal (including delirium tremens, dts, seizures) icu care nutrition: glycemic control: lines: 18 gauge - [**2124-2-1**] 11:00 am multi lumen - [**2124-2-1**] 12:49 pm arterial line - [**2124-2-1**] 12:50 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: dnr / dni disposition: ------ protected section ------ micu attending addendum i saw and examined the patient, and was physically present with the icu team for the key portions of the services provided. i agree with the note above, including the assessment and plan. i would emphasize and add the following points: 71m etoh cirrhosis, tips [**1-28**] for refractory ascites, progressive encephalopathy, hypoxemia following attempted ngt placement. intubated, cvl, a-line, s/p paracentesis w/subseq pressor requirement. events family mtg [**2-2**] - determined to be dnr, if not improving [**2-3**] then ?cmo [**2-4**]. will reassess after family meeting [**2-4**]. chest cta showed no pe, sm bilat pleural effusions. lenis neg for dvt. hypotensive overnight s/p bolus x 2, increased levophed. exam notable for elderly gentleman, intubated and sedated no response to voice. tm 96.1 bp 125/70 hr 87af rr 18 with sat 95 on vac 500x18 5 0.4 7.36/40/93. diffuse rhonchi, irreg s1s2 2/6sm. distended, tympanitic abdomen. 2+ edema upper > lower extremities. erythematous rash on abdomen. labs notable for wbc 5k, hct 27, k+ 3.3, cr 1.0, na 143, inr 2.3. cxr with l>r lung asd changes. agree with plan to reassess today/tomorrow after repeat family meeting. given new rash will stop antibiotics. no evidence for pe/dvt. will manage encephalopathy with endoscopic ngt placement, lactulose, rifaximin, and reversal of hypernatremia. no evidence of sbp. care and overall prognosis reviewed with daughter yesterday. [**name2 (ni) **] would not want chronic support, but will continue with current level of care in an effort to reverse encephalopathy. currently we are not giving supplemental feeds and this will need to be readdressed if plan to continue current therapy is decided in tomorrow s meeting. remainder of plan as outlined above. discussed with brother of patient today. patient is critically ill total time: 50 min ------ protected section addendum entered by:[**name (ni) 20**] [**last name (namepattern1) 885**], md on:[**2124-2-3**] 12:06 ------",1
21,"chief complaint: 24 hour events: arterial line - stop [**2124-2-4**] 12:00 am made dnr yesterday. no more invasive procedures. family considering cmo. allergies: codeine nausea/vomiting ambien (oral) (zolpidem tartrate) unknown; last dose of antibiotics: vancomycin - [**2124-2-2**] 09:39 pm piperacillin/tazobactam (zosyn) - [**2124-2-3**] 12:41 am infusions: midazolam (versed) - 3 mg/hour fentanyl - 100 mcg/hour norepinephrine - 0.24 mcg/kg/min other icu medications: pantoprazole (protonix) - [**2124-2-3**] 08:04 pm midazolam (versed) - [**2124-2-4**] 12:06 am fentanyl - [**2124-2-4**] 12:07 am heparin sodium (prophylaxis) - [**2124-2-4**] 04:27 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2124-2-4**] 05:42 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.9 c (98.5 tcurrent: 35.8 c (96.5 hr: 70 (65 - 78) bpm bp: 113/65(77) {62/42(47) - 125/74(83)} mmhg rr: 17 (16 - 22) insp/min spo2: 98% heart rhythm: af (atrial fibrillation) cvp: 12 (8 - 17)mmhg total in: 4,163 ml 420 ml po: tf: ivf: 3,963 ml 420 ml blood products: 200 ml total out: 765 ml 170 ml urine: 765 ml 170 ml ng: stool: drains: balance: 3,398 ml 250 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml rr (set): 18 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi deferred: neuromusc block pip: 19 cmh2o plateau: 14 cmh2o compliance: 55.6 cmh2o/ml spo2: 98% abg: ///23/ ve: 8.9 l/min physical examination general: intubated, sedated, opens eyes to sternal rub, not responsive to voice or following commands, mae heent: perrl, pinpoint, op with dried blood, no e/o recent bleed neck: unable to appreciate any elevated jvp heart: rrr 2/6 systolic murmur best heard at lusb radiating to carotids lungs: coarse bs, diminished in anterior lung fields. abd: +bs, slightly hypoactive, nt, mildy distended, soft ext: trace edema b/l with chronic venous stasis changes (l>r), wwp, ue edema bl l>r neuro: limited by his mental status, spontaneously moves all 4 extremities,responsive to sternal rub . skin: multiple echymosis labs / radiology 110 k/ul 10.1 g/dl 140 mg/dl 1.1 mg/dl 23 meq/l 3.9 meq/l 16 mg/dl 114 meq/l 144 meq/l 29.0 % 7.8 k/ul [image002.jpg] [**2124-2-1**] 03:52 pm [**2124-2-1**] 05:20 pm [**2124-2-1**] 08:39 pm [**2124-2-2**] 04:07 am [**2124-2-2**] 04:46 am [**2124-2-2**] 06:43 am [**2124-2-3**] 01:58 am [**2124-2-3**] 02:15 am [**2124-2-3**] 05:57 pm [**2124-2-4**] 03:24 am wbc 7.1 4.6 5.2 7.8 hct 27.6 26.7 27.1 29.0 plt 131 110 96 110 cr 1.4 1.4 1.0 1.0 1.1 tco2 20 21 23 23 24 glucose 156 175 128 138 140 other labs: pt / ptt / inr:23.5/58.0/2.3, ck / ckmb / troponin-t:468/12/0.06, alt / ast:13/34, alk phos / t bili:32/4.4, differential-neuts:78.8 %, lymph:10.7 %, mono:7.8 %, eos:2.5 %, lactic acid:1.8 mmol/l, albumin:3.7 g/dl, ldh:250 iu/l, ca++:8.7 mg/dl, mg++:1.7 mg/dl, po4:2.3 mg/dl assessment and plan 71 gentleman with alcoholic cirrhosis c/b portal htn, refractory ascites s/p tips [**2119**] found to have occluded tips by u/s in [**12-18**] now s/p tips revision [**2124-1-28**] and portal vein thrombolysis transferred with hypoxia and altered mental status now intubated with persistent hypotension and pressor requirement. . # hypoxemic respiratory failure: hypoxia most likely secondary to aspiration given witnessed aspiration event, decreased o2 sats, new tachypnea, infiltrates on cxr. hap less likely since no fever or elevated wbc. also concerning for pe given rv dilation and hypokinesis but none seen on cta. other less likely etiologies include hps. - will d/c vanc/zosyn for hap coverage since no clear indication and may be causing drug reaction - would continue current vent settings for now - serial abgs to trend lactate, monitor oxygenation and ventilation - cta today to eval for pe . # mental status changes: timing coincides with tips revision. likely multifactorial secondary to post op delirium, encephalopathy from patent tips and lack of lactulose, underlying cognitive dysfunction, and possible infection. head ct negative for bleed but his ventricles were enlarged with ? communicating hydrocephalus. per discussion with neurology, hydrocephalus unlikely cause of ms changes and is likely chronic. head ct did not show any acute signs of hemorrhage which was concern while on anticoagulation. also concern for sepsis with low uop, borderline low bps. on vanc, zosyn now for asp pna and empiric sbp treatment but will stop since no cx data, no fevers and may be causing adverse reaction with rash. para negative for sbp. ua negative. bld cx ngtd. also on the differential will be alcohol withdrawal but less likely given time course, has been in hospital since [**1-21**] and only received ativan after tips on [**1-28**]. - unable to treat encephalopathy without ngt - on fentanyl and versed for sedation, will titrate to avoid agitation and oversedation - follow up blood cx, urine cx, ascetic cx, obtain sputum cx and restart abx if indicated - could consider occluding tips if unable to reverse ms changes but family not interested in invasive procedures . # hypotension: hypotension likely multifactorial secondary to liver disease, ventilator and peep, rv impairment, infection/sepsis. - continue pressors (currently on levophed) titrate to lower map 60s - would not add second pressor without family discussion regarding management, just bolus for now, accept lower bps - follow uop # tips revision: had revision [**1-28**]. thrombolysis, angioplasty done with gradient of 6 after procedure was finished. per ir, no need for heparin. briefly on lovenox but discontinued since pt at risk for bleeding. ruq us demonstrates flow but could not assess gradient since agitated. - f/u further ir recs - consider reversing tips due to gross encephalopathy but pt s family does not want further invasive procedures . # portal vein thrombosis: s/p thrombolysis and angioplasty. - no anti-coag for now, has inr>2.0 # pacemaker malfunction/ecg changes: pacemaker not functioning properly per ep secondary to microdislodgement of rv lead per ep. has a history of high grade avb. if recovers, will need lead revision. - appreciate ep recs - no nodal agents - telemetry # anemia: transfused 1 unit on this admission, hct relatively stable since around baseline and bumped appropriately to i unit. no egd since [**2119**]. theoretically, if tips patent would not need prophylaxis for varices but tips gradient unknown. if hct decreases, will consider checking [**hospital1 7**] hcts . # acute renal failure: baseline cr~1. cr stable to improved, 1 today. has had good uop last 24 hours, requiring boluses x 2 for low uop and bp but seems to respond well to this. - holding lasix and spironolactone - ns boluses prn low uop - maintain map 60s to maintaijn perfusion pressure - [**hospital1 7**] albumin . # gout: on colchicine . # le edema: pt had lle edema greater than r concerning for dvt. lle us negative for dvt but limited study due to agitation. lenis negative for dvt . # alcoholic cirrhosis: inactive on transplant list. - hold lasix and spironolactone given arf - appreciate hepatology recs . # thrombocytopenia: plt count stabilized, c/w prior baseline 80s-100s . # dm2: maintain glycemic control with hiss. . # fen/gi unable to feed since cannot place ngt/ogt per pt request , replete lytes prn . # ppx - sub q heparin, ppi . # access - piv , rij cvl and left radial a line placed . # code - full (confirmed with pt). pt's daughter [**name (ni) 4522**] [**numeric identifier 4523**]. cell [**telephone/fax (1) 4524**] . # dispo - pending improvement in mental status hypotension (not shock) airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) altered mental status (not delirium) alteration in nutrition .h/o alcohol withdrawal (including delirium tremens, dts, seizures) icu care nutrition: glycemic control: lines: 18 gauge - [**2124-2-1**] 11:00 am multi lumen - [**2124-2-1**] 12:49 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: dnr / dni disposition:",
22,"admission date: [**2130-12-15**] discharge date: [**2130-12-18**] date of birth: [**2057-10-30**] sex: m service: diagnosis: sepsis. hospital course: (summary of the patient's medicine intensive care unit course from [**2130-12-15**] until [**2130-12-18**]) history of present illness: the patient is a 73 year old male with recently diagnosed nonhodgkin's lymphoma in [**2130-9-11**]. the patient presented with low back pain and was found to have a poor compression. the patient was treated with radiation and steroids from [**month (only) **] until [**2130-10-18**] and then discharged to [**hospital **] rehabilitation for rehabilitation. the patient was readmitted on [**2130-11-8**] for rituxan treatment per oncology, dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **]. after receiving first dose of rituxan the patient had an adverse reaction including hypotension, tachycardia, fever and hypoglycemia. the hospital course was notable for syndrome of inappropriate antidiuretic hormone, change in mental status and anemia. the patient was then discharged to [**hospital1 **] on [**2130-11-12**]. the patient now returns to the emergency room on the day of admission with lethargy and shortness of breath. the patient has been undergoing treatment with levofloxacin for presumed pneumonia since [**12-11**]. at [**hospital1 **] the patient was short of breath and was given in addition to levofloxacin vancomycin for treatment of presumed pneumonia and referred to the emergency room. in the emergency room the patient had a temperature of 100.8 and was hypotensive with a systolic blood pressure of 77. in addition, the patient was in mild respiratory distress and was hypoxic with an oxygen saturation of 88% on 4 liters. the patient was diagnosed with presumed sepsis from pneumonia and started on intravenous fluid resuscitation, and sent to the intensive care unit. past medical history: 1. nonhodgkin's lymphoma as per history of present illness, follicular. 2. type 1 diabetes. 3. benign prostatic hypertrophy. 4. anemia. 5. depression. medications on admission: 1. celexa 20 mg p.o. q.d. 2. aranesp 100 mcg q. weekly 3. colace 100 mg p.o. b.i.d. 4. lantis insulin 10 units q. pm 5. prevacid 30 mg p.o. q.d. 6. magnesium oxide 400 mg p.o. q.d. 7. remeron 15 mg p.o. q.h.s. 8. multivitamin one tablet p.o. q.d. 9. senna two tablets p.o. q.d. 10. levaquin 500 mg p.o. q.d. started on [**2139-12-16**]. humalog sliding scale 201 to 250 2 units, 251 to 300 4 units, 301 to 350 6 units, 351 to 400 8 units, 401 to 450 12 units, 451 to 500 15 units. allergies: rituxan. social history: the patient is single, has no children. the next closest [**doctor first name **] is his brother. lives alone prior to recent illnesses. physical examination on admission: general: alert and oriented to person, hospital and year but drowsy. head, eyes, ears, nose and throat, oropharynx with dry mucous membranes, no jugulovenous distension. cardiovascular, regular rate and rhythm with no murmurs. lungs with crackles at bases bilaterally. abdomen, soft, nontender, nondistended. positive hepatomegaly. spleen not palpated. extremities, no edema, 2+ dorsalis pedis pulses. skin, warm. laboratory data: significant laboratory data on admission revealed white count 16.9, hematocrit 27.1, platelets 329, creatinine normal at 0.7. microbiology - blood cultures from [**2130-12-15**] with no growth. urine, legionella antigen negative. chest x-ray from [**2130-12-15**], development of diffuse bilateral interspace disease. echocardiogram, [**2130-12-18**], ejection fraction of 45%, left atrium normal in size. left ventricular wall thickness and cavity size were normal. mild globar left ventricular hypokinesis, right ventricular systolic function was normal. no valvular disease. no pericardial effusion. hospital course: while the patient was in the medicine intensive care unit from [**12-15**] to [**12-18**]: 1. sepsis - the patient presented with fever of 100.8, hypotension and tachycardia consistent with sepsis. differential diagnosis included pneumonia with admission chest x-ray showing bilateral diffuse patchy infiltrate. in addition, the patient with picc line and concern for line sepsis. the patient was started on broad spectrum antibiotics with vancomycin, levaquin, ceptaz and flagyl. the patient was volume resuscitated with 10 liters of normal saline. the patient was started on stress dose steroids with hydrocortisone 100 mg q. 8. the patient required pressors with levophed to maintain blood pressure for approximately 24 hours and was then weaned off. the patient's respiratory status remained stable on 4 liters of nasal cannula. for evaluation of pneumonia, the patient was unable to produce sputum sample on admission. blood cultures drawn showed no growth. in addition the picc line was removed and tip culture was sent which showed no growth. likely the patient has atypical pneumonia given chest x-ray findings. on hospital day #3 ceftazidime and flagyl were discontinued as unlikely that the patient had aspiration or pseudomonas pneumonia. 2. hematology/oncology - patient with a history of nonhodgkin's lymphoma, follicular type. he received one dose of rituxan in [**2130-10-11**] and had an adverse reaction. in reviewing medical records, the patient with abdominal computerized tomography scan in [**month (only) 359**] which showed retroperitoneal and mesenteric lymphadenopathy. in addition there was lymphadenopathy at the gastroesophageal junction and anterior pancreas. there was also noted to be an l3 vertebral body lytic lesion. further chemotherapy treatment was postponed given current active infection issue. 3. cardiovascular - the patient with no known history of coronary artery disease. echocardiogram done on hospital day #3 showed moderately reduced left ventricular ejection fraction of 45% with no focal wall motion abnormalities or valvular disease. after receiving multiple intravenous fluid boluses for volume resuscitation for treatment of sepsis, the patient was subsequently diuresed when hemodynamically stable. 4. psychiatry - the patient with a history of paranoid depression. on the hospital day #3, the patient was restarted on outpatient medications, celexa and remeron. further hospital course while on medical floor to be dictated. [**first name8 (namepattern2) **] [**last name (namepattern1) 1296**], m.d. [**md number(1) 292**] dictated by:[**last name (namepattern1) 1297**] medquist36 d: [**2130-12-18**] 14:11 t: [**2130-12-18**] 15:53 job#: [**job number 1298**]",1
23,"admission date: [**2145-3-11**] discharge date: [**2145-3-17**] date of birth: [**2101-3-21**] sex: f service: medicine allergies: clindamycin / zemplar / levofloxacin / trazodone / doxycycline attending:[**first name3 (lf) 348**] chief complaint: hypotension, line infection major surgical or invasive procedure: ir placement on tunelled hd line on [**3-16**] history of present illness: 43f with esrd on hd, dm1, cad s/p cabg, h/o poor access with failed av fistulas presenting with pus coming from hd line. systolic bps to 80s, patient appeared sick and was not mentating well. lactate was 3.0. therefore peripheral dopamine started (patient did not want central line). she did not have arterial line. on arrival on the floor hypotensive to sbp of 84, but talkative, mentating. says baseline bp is in 110s. given that patient does not have dialysis access, she was not given ivf. pressure has now improved to mid-90s systolic. of note, patient admitted to [**hospital1 18**] [**12/2144**] for tunelled line infection. the line was removed and replaced at that time. a tte did not show evidence of endocarditis at that time. a tee was attempted but not completed because of patient intolerance. she denies known exposure to line site to cause infection. she wonders about sterility of dressings at her outpatient hd center. upon arrival at the [**hospital1 18**] ed, patient was febrile to 101.5, later peaking at 102.6. central line considered but patient refused. past medical history: 1. cad s/p cabg x 3 in [**10-27**] 2. dm1 since age of 6 3. esrd on hd, being worked up for transplant 4. h/o mrsa rt stump infection 5. anemia 6. pvd s/p tma 7. h/o epistasis from right nostril 8. bell's palsy (right side, s/p valtrex x 7 days, last [**1-2**]) 9. aaa repair in '[**39**] 10. h/o previous tunelled line infection. social history: no tobacco, alcohol or illicit drug use family history: mother: [**name (ni) 2481**] disease and cad father: deceased from prostate ca siblings are all alive and well physical exam: exam on transfer to floor vitals: t 94.5 84/doppler 67 16 98%ra general: well-appearing neck: no jvd cv: rrr nl s1, s2 no murmurs lungs: crackles at bases bilaterally abd: soft, nt, nd, +bs ext: no c/c; 1+ pitting edema in [**name prefix (prefixes) **] [**last name (prefixes) **]/l neuro: mentating well, conversant, slightly aggitated/aggravated with concern over bp skin: multiple excoriations and scabbed over lesions on arms pertinent results: cxr on admission: findings: there has been interval placement of a large bore dual-lumen dialysis catheter with the distal tip projecting over the right atrium. prominence of the [**last name (prefixes) 1106**] pedicle is again identified with mild cephalization. this is relatively stable. no overt edema is noted. there is no consolidation. lung volumes are low. the cardiac silhouette remains enlarged, but stable. clips and median sternotomy wires are consistent with prior cabg. no effusion or pneumothorax is evident. the bones are diffusely osteopenic. the patient has had prior cholecystectomy. impression: interval placement of a dialysis catheter. stable findings otherwise with no definite superimposed acute process. . hd line placement: impression: uncomplicated ultrasound and fluoroscopically guided tunneled dialysis catheter placement via the left internal jugular venous approach. . [**2145-3-11**] 05:55pm blood wbc-9.4 rbc-4.18*# hgb-13.4# hct-42.9# mcv-103* mch-32.0 mchc-31.2 rdw-19.8* plt ct-161 [**2145-3-17**] 10:50am blood wbc-6.1 rbc-3.97* hgb-11.9* hct-39.7 mcv-100* mch-29.9 mchc-29.8* rdw-20.5* plt ct-205 [**2145-3-11**] 05:55pm blood neuts-89.8* bands-0 lymphs-7.0* monos-2.1 eos-0.8 baso-0.4 [**2145-3-13**] 02:34am blood neuts-74.1* lymphs-16.7* monos-8.3 eos-0.1 baso-0.9 [**2145-3-11**] 05:55pm blood pt-15.8* ptt-34.1 inr(pt)-1.4* [**2145-3-16**] 05:35am blood pt-14.0* ptt-30.3 inr(pt)-1.2* [**2145-3-11**] 05:55pm blood glucose-287* urean-24* creat-3.5*# na-136 k-4.2 cl-91* hco3-27 angap-22* [**2145-3-17**] 10:50am blood glucose-320* urean-51* creat-5.7*# na-134 k-4.9 cl-95* hco3-22 angap-22* [**2145-3-13**] 07:57am blood vanco-11.4 [**2145-3-15**] 06:30am blood vanco-9.4* [**2145-3-16**] 03:40pm blood vanco-20.5* [**2145-3-11**] 06:11pm blood lactate-3.0* . [**month/day/year **] (4/34): prelim the left atrium is elongated. the left atrium is dilated. there is severe regional left ventricular systolic dysfunction with akinesis and thinning of the entire inferior wall and hypokinesis of the remaining segments. diastolic function could not be assessed. the remaining left ventricular segments are hypokinetic. right ventricular chamber size is normal. with borderline normal free wall function. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. there is no aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. mild (1+) mitral regurgitation is seen. [due to acoustic shadowing, the severity of mitral regurgitation may be significantly underestimated.] the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: no vegetation seen. mild mitral and tricuspid regurgitation. severe regional and moderate global lv systolic dysfunction. compared with the prior study (images reviewed) of [**2144-12-25**], the pulmonary artery systolic pressures are slightly elevated. the other findings are similar. if clinically suggested, the absence of a vegetation by 2d echocardiography does not exclude endocarditis. brief hospital course: #mrsa sepsis patient has history of line sepsis previously with mrsa. source of sepsis unclear. [**name2 (ni) **] had a tte to evaluate valves which was of suboptimal quality but did not show large vegetations. plan is for two weeks of treatment with vancomycin starting on [**3-12**]. if, after two week course of treatment, patient has persistent bacteremia, she should be considered for tee. . #hypotension when hypotensive on admission, patient was not mentating well and had elevated lactate. hypotensive on the floor to mid-80s systolic however patient was mentating well. on discharge bp 116-128/64-72. she required peripheral dopamine in the icu. . #esrd on hd patient was without hd between [**3-11**] and [**3-16**]. she did not have uremic signs or symptoms except for some non-specific itching. we continued nephrocaps, cinacalcet, and calcium carbonate. she may have a high-protein diet while on hd. # dm i continued outpatient insulin regimen of 12 units nph qam. fasting blood glucose in am was elevated, however given multiple periods of being npo, her regimen was not adjusted. this may be titrated at rehab. . # diarrhea patient had 36hrs of diarrhea and was c.diff negative x3. diarrhea resolved with imodium. she was afebrile and had minimal abdominal pain. . # skin breakdown patient was admitted with skin breakdown felt to be from prolonged imobilization. she was treated with therapeutic boots, air mattress, and skin care. she refused air mattress after an explanation of the risks and benefits including development of pressure ulcers. medications on admission: 1. folic acid 1 mg po qd 2. nephrocaps po qd 3. calcium carbonate 1000 mg po qid w/ meals 4. pantoprazole 40 mg po qd 5. insulin nph 12 u qam w/ insulin lispro sliding scale 6. cinacalcet 60 mg po qd 7. heparin 5000 u sc tid 8. aspirin 325 mg po qd . allergies/adverse reactions: clindamycin (diarrhea) zemplar (rash) levofloxacin (diarrhea) trazodone (unknown) doxycycline (nausea/vomiting) discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 3. heparin (porcine) 5,000 unit/ml solution sig: one (1) inj injection tid (3 times a day). 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po three times a day as needed: give with meals. 8. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 9. cinacalcet 30 mg tablet sig: two (2) tablet po daily (daily). 10. cortisone 1 % cream sig: one (1) appl topical qid (4 times a day) as needed for itching. 11. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po tid (3 times a day) as needed for itching. 12. insulin nph human recomb 100 unit/ml cartridge sig: twelve (12) units subcutaneous qam. 13. insulin lispro 100 unit/ml cartridge sig: sliding scale subcutaneous four times a day. 14. loperamide 2 mg capsule sig: one (1) capsule po qid (4 times a day) as needed. 15. vancomycin in dextrose 1 gram/200 ml piggyback sig: one (1) gram intravenous hd protocol (hd protochol) for 8 days: last day [**3-25**]. discharge disposition: extended care facility: courtyard - [**location (un) 1468**] discharge diagnosis: primary: mrsa septic shock infected tunelled hd line diabetes mellitus type i discharge condition: good. blood pressure 116-128/64-72 at discharge. discharge instructions: you were admitted because of septic shock with pus coming from your hemodialysis catheter. this was treated with a stay in the icu with temporary use of medications to support your blood pressure. the old line was removed and your were given antibiotics. you have had a new line put in for dialysis access. you had an [**location (un) 461**] to find a source for your recurrent mrsa infections. it is not clear why you are having recurrent infections of your hemodialysis line. you will continue to get vancomycin at dialysis for a total of two weeks. after this time if you have recurrent positive cultures, we would recommend having a trans-esophageal [**location (un) 461**]. please speak with your kidney doctor regarding this. followup instructions: please followup with your pcp when you leave rehab. please continue to have dialysis",1
24,"admission date: [**2120-9-20**] discharge date: [**2120-9-30**] date of birth: [**2075-5-1**] sex: f service: medicine allergies: no known allergies / adverse drug reactions attending:[**first name3 (lf) 3958**] chief complaint: presyncope major surgical or invasive procedure: pericardial window history of present illness: this is a 45 y/o female with past medical history of hypothyroidism presenting initially for an urgent care visit with an episode of diaphoresis and presyncope several hours prior. the patient has had ~1 month of bilateral neck discomfort associated with mild dyspnea on exertion. her neck pain improved with physical therapy and her neck pain improved. she now reports worsening doe and worsening neck pain over the past 1 1/2 weeks. she now has difficulty walking up a single flight of stairs. additionally, she reports that for the past few days, she hasn't been ""feeling herself"", with fatigue, nausea, vomitting, decreased po. on day of presentation she was leaving work, walking to car when had acute onset of diaphoresis and presycnope associated with sob; no fall /headstrike. no palpitations. presented to clinic for further evaluation. in clinic triage noted to be tachycardic to 116. on review of systems she reports low grade fevers (but has been taken ibuprofen regularly), 5 pounds of weight loss over past 2 weeks, day&nightime sweats (and felling 'hot'), with increasing nausea/vomitting. she has had no lymphadenopathy, abdominal pain, change in her bowel or bladder habits, muscle or joint pain. of note, on review of history had recent tsh of .088 [**7-26**], for which she had levoxyl dose decreased and cytomel dose kept the same. in the ed, initial vitals were 100.0 116 126/88 18 99% labs and imaging significant for new anterior mediastinal mass. she had elevated wbc to 14.1 with 89.7%neutrophils, hb:10.4 plt:468. chem 7 wnl. tsh, ft4 pending. d-dimer 5515, but cta negative for pe. patient given zofran. on arrival to the floor, patient complained of pleuritic chest pain and intermittent nausea past medical history: hypothyroidism/hashimoto's disease dyspepsia hepatitis irritable bowel syndrome s/p fibroadenoma excision, right breast varicose veins, s/p sclerotherapy allergic rhinitis tonsillectomy/adenoidectomy social history: levothyroxine [levoxyl] 88mcg daily liothyronine [cytomel] 10 mcg qam, 2.5 mcg qpm calcium and vitamin d two tablets in the evening, vitamin d [**2108**] units a day, magnesium oxide 400 mg a day, metamucil, selenium 100 mcg a day, vitamin b complex with biotin. family history: father living, age 73, hypertension, positive for h. pylori on endoscopy, history of colon cancer, prediabetes. mother living, age 66, high cholesterol. two brothers, one with hypertension and ulcers. one brother and sister who are healthy. daughter is 19 years old, graduated from high school and going to [**university/college 3959**]in the fall, going to live at home. son [**name (ni) **] 17 years old, going into his senior year of high school. family history positive for breast cancer in two maternal aunts. family history negative for coronary artery disease, mi, cva, and diabetes mellitus. physical exam: admission exam: vs: t=98.4 bp=109/77 hr=120 rr=19 o2 sat= 97%ra general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. neck: supple with jvp of 10 cm. cardiac: tachycardic, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were somewhat labored intermittently, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ discharge exam: general - well-appearing woman in nad, comfortable, appropriate heent - nc/at, perrla, eomi, sclerae anicteric, mmm, op clear neck - supple lungs - clear to ausculation bilaterally heart - pmi non-displaced, rrr, no mrg, nl s1-s2 abdomen - nabs, soft/nt/nd, no masses or hsm, no rebound/guarding extremities - wwp, 2+ peripheral pulses (radials, dps); 1+ trace edema bilaterally skin - no rashes or lesions lymph - no cervical, axillary, or inguinal lad neuro - awake, a&ox3, pertinent results: admission labs: [**2120-9-19**] 06:18pm wbc-14.1*# rbc-3.73* hgb-10.4* hct-32.6* mcv-87 mch-27.8 mchc-31.8 rdw-13.9 [**2120-9-19**] 06:18pm neuts-89.7* lymphs-5.0* monos-5.0 eos-0.2 basos-0.2 [**2120-9-19**] 06:18pm plt count-468*# [**2120-9-19**] 06:18pm hcg-<5 [**2120-9-19**] 06:18pm tsh-0.67 [**2120-9-19**] 08:14pm d-dimer-5515* [**2120-9-19**] 06:18pm glucose-125* urea n-16 creat-0.5 sodium-138 potassium-4.7 chloride-101 total co2-26 anion gap-16 [**2120-9-20**] 09:13am cea-<1.0 [**2120-9-20**] 04:28am alt(sgpt)-41* ast(sgot)-19 ld(ldh)-485* alk phos-220* tot bili-0.6 [**2120-9-20**] 09:21am blood type-art po2-87 pco2-25* ph-7.43 caltco2-17* base xs--5 discharge lab [**2120-9-30**] 06:15am blood wbc-21.4* rbc-3.82* hgb-10.7* hct-31.9* mcv-84 mch-28.0 mchc-33.5 rdw-13.5 plt ct-333 [**2120-9-30**] 06:15am blood neuts-95.2* lymphs-2.7* monos-0.4* eos-1.7 baso-0 [**2120-9-30**] 06:15am blood glucose-116* urean-8 creat-0.5 na-137 k-4.1 cl-102 hco3-28 angap-11 [**2120-9-30**] 06:15am blood alt-30 ast-20 ld(ldh)-249 alkphos-135* totbili-1.0 [**2120-9-30**] 06:15am blood calcium-8.8 phos-2.8 mg-2.1 uricacd-3.1 micro urine culture (final [**2120-9-27**]): culture workup discontinued. further incubation showed contamination with mixed skin/genital flora. clinical significance of isolate(s) uncertain. interpret with caution. proteus mirabilis. 10,000-100,000 organisms/ml.. presumptive identification. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ proteus mirabilis | ampicillin------------ <=2 s ampicillin/sulbactam-- <=2 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s pathology [**9-20**] pericardium, mediastinal mass biopsy specimen #1: pericardium, biopsy (a). diagnosis: cardiac muscle and fibroadipose tissue with fibrin deposition and granulation tissue reaction. there is no morphologic evidence of involvement by lymphoma. specimen #2: soft tissue mass, right anterior mediastinum, biopsy (b-c). diagnosis: diffuse large b-cell lymphoma, primary mediastinal (thymic) type, see note. specimen #3: soft tissue mass, right anterior mediastinum, biopsy (d-e). diagnosis: diffuse large b-cell lymphoma, primary mediastinal (thymic) type, see note. note: h&e sections (b through e) reveal fibrous tissue with abundant geographic necrosis and infiltration by an atypical lymphoid population in an invasive and reticulated growth pattern with delicate interstitial fibrosis. the tumor cells are large with moderately abundant amphophilic cytoplasm. the nuclei have pale chromatin, irregular and angulated nuclear contours, and small inconspicuous nucleoli. scattered mitoses and apoptotic bodies are seen. by immunohistochemistry, tumor cells are pan reactive with cd45 and in addition, immunoreactive for cd20 and pax-5, with co-expression of cd30, mum1, and bcl-6. the admixed reactive t-cells are positive for cd3 and cd5. the tumor is negative for cd10, cd15, and cd56, which shows only rare scattered positive cells. the tumor cells are negative for cytokeratin cocktail (which stains the fibroblasts), synaptophysin, s-100, and tdt. the proliferation index, by mib-1 staining, is approximately 80-90%. the combined clinical, morphologic, and immunophenotypic findings are most consistent with the diagnosis of primary mediastinal large b-cell lymphoma. [**2120-9-23**] flow cytometry report flow cytometry immunophenotyping the following tests (antibodies) were performed: hla-dr, fmc-7, kappa, lambda, and cd antigens 3,5,10,19.20,23,45. results: three color gating is performed (light scatter vs. cd45) to optimize lymphocyte yield. b cells comprise 1% of lymphoid-gated events, (<1% of total events), and do not express aberrant antigens. t cells comprise 63% of lymphoid gated events, 3% of total events, and express mature lineage antigens. interpretation nonspecific t cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by lymphoma are not seen in specimen. correlation with clinical findings and morphology (see s12-40728k) is recommended. flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. [**2120-9-23**] bone marrow biopsy diagnosis: hypercellular bone marrow with maturing trilineage hematopoiesis. there is no morphologic evidence of involvement by lymphoma. microscopic description peripheral blood smear: the smear is adequate for evaluation. erythrocytes are decreased, with mild anisopoikilocytosis including occasional echinocytes, and rare target cells. the white blood cell count is normal. occasional hypersegmented neutrophils are seen. the platelet count appears normal. occasional large platelets are seen. a manual differential shows: 97% neutrophils, 0% bands, 3% lymphocytes, 0% monocytes, 0% lymphocytes, 0% eosinophils, 0% basophils. aspirate smear: the aspirate material is adequate for evaluation. m:e ratio is 1.5:1. erythroid precursors are relatively proportionately decreased in number and exhibit overall normoblastic maturation with rare cells with irregular contours. myeloid precursors are relatively proportionately increased in number and show normal maturation. megakaryocytes are increased number. abnormal forms are not seen. a 500 cell manual differential shows: 0% blasts, 4% promyelocytes, 7% myelocytes, 8% metamyelocytes, 38% bands/neutrophils, 37% erythroids, 6% lymphocytes, 0% plasma cells. biopsy slides: the core biopsy material is adequate for evaluation. it consists of a 1.1 cm core biopsy of trabecular marrow with a cellularity of 70%. m:e ratio estimate is increased. the bone appears mildly osteopenic. erythroid precursors are relatively proportionately decreased in number in number and have overall normoblastic maturation. myeloid precursors are relatively proportionately increased in number with normal maturation. megakaryocytes are increased in number, with focal loose and tight clustering. imaging 2-d echocardiogram [**2120-9-19**]: the estimated right atrial pressure is at least 15 mmhg. left ventricular wall thicknesses are normal. 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 65%). the right ventricular free wall is thick. there is a 1 cm thick soft tissue rind abutting the right ventricular free wall, largest at the atrioventricular groove. this could represent an acoustically dense epicardial fat pad or an extensive epicardial tumor/metastasis. right ventricular free wall infiltration cannot be excluded, especially in light of the thickened, hypocontractile appearance. right ventricular chamber size is normal with depressed free wall contractility. the aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. the mitral valve leaflets are structurally normal. the pulmonary artery systolic pressure could not be determined. there is a large pericardial effusion. the effusion is echo dense, consistent with blood, inflammation or other cellular elements. stranding is visualized within the pericardial space c/w organization. there is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. consider cardiac mri to better assess the possibility of right ventricular free wall infiltration read by: [**first name8 (namepattern2) **] [**name8 (md) **], md echocardiogram post-pericardial window: [**2120-9-21**] impression: normal biventricular systolic function. abnormal septal motion, likely due to effusive-constrictive physiology (commonly seen for a limited time after pericadiocentesis). mediastinal mass abutting the right ventricular free wall. compared with the prior study (images reviewed) of [**2120-9-19**], the previously seen pericardial fluid is no longer present. both ventricles appear larger as a result. no evidence of tamponade physiology. read by: [**first name4 (namepattern1) **] [**last name (namepattern1) **] echocardiogram [**2120-9-23**] left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the mitral valve appears structurally normal with trivial mitral regurgitation. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. there is an anterior space which most likely represents a prominent fat pad. there are no echocardiographic signs of tamponade. there is a mediastinal mass compressing the heart. impression: no evidence of significant pericardial fluid or tamponade physiology. mediastinal mass anterior to the right ventricle. compared with the prior study (images reviewed) of [**2120-9-21**], the septal bounce has resolved. other findings are similar. [**2120-9-30**] echo 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. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is a trivial/physiologic pericardial effusion. there is an anterior space which most likely represents a prominent fat pad. there are no echocardiographic signs of tamponade. brief hospital course: this is a 45 year f with past medical history of hypothyroidisim presenting with diaphoresis, presyncope, and severe doe and found to have an anterior medialstinal mass consistnet with primary mediastinal large b- cell lymphoma on pathology, transfered from ccu after pericardial window and resolution of tamponade to bmt service for intiation of r-[**hospital1 **] #primary mediastinal large b-cell lymphoma- the patient presneted with dyspnea and pleuritic chest pain. a ct chest done as part of her evaluation was notable for a anterior mediastinal mass. biopsy of the pericardium and mediastinal mass was positve for b-cell lymphoma. r-[**hospital1 **] chemotherapy was intiated for treatement, and a bone marrow biospy was done. the patient experienced an adverse reaction during infusion of rituxan ( see below), but tolerated the remainder of her treatment course without complication. she will follow up with her primary oncologist dr. [**last name (stitle) **] for further mangement. # afib w/ rvr- the patient triggered twice during infusion of rituxan on day 1 of r-chop. during the infusion of rituxan on day 1 of r-chopthe patiet became hyptoensive to 80s/50s, with associated palpitations, but arousable when the rate of rituxan was increased from 50 to 100 mg/hr. the patient was found to be in afib with rvr ( hrs 130s-150s) on telemetry ( confirmed by ekg). rituxan was stopped, iv hydrocortisone 100mg x2 was and 1 l ivfs were given. the patient convereted to nsr hr in he 80s with out any intevention, and resolution of palpitation. the bmt atending was notified and the decision wasmade to restart rituxan at 0mg/hr,and if an further complications would stop completely. two hours after inital episode the patient was satiing 91 on 2l, was normotensive with hr 80. rituxan was stopped pending repeat echo, as asses cardiac function. 3 hours after discontinuing rituxan the patient returned to afib with rvt, hr 130s, although the patient was asymptomatic at this time. she received iv metoprol mg x 2, and started on metoprolol 12.mg po id. she converted back to nsr 1 hour later. an echo was done the next morning, significant for an lvef > 55%. her afib was most likley a exaggerated inflammatory reaction to rituxan. she was evaluated by cardiology who did not recommend long term anticogualtion for her afib, and to rate control with nodal agents if recurred. ?she had no further episodes during her hospital course # pulmonary embolism- the patient was found to have a right subsegmental pe and on cta. she was treated with a heparin gtt and transitioned to lovenox on discharge. duration of therapy to be determined by primary oncologist. # pericardial effusion/tamponade- the patient most likely had a malignant effusion secondary to her primary mediastinal large b-cell lymphoma. went for pericardial window [**9-20**], drained 250cc fluid. gram stain of fluid and tissue negative for organisms, 2+ polys and 0 polys, respectively. pericardial drain was pulled on [**9-21**] and f/u echo showed resolution of pericardial effusion. she was monitored with serial echos during her hospital course which did not show reaccumulation of the pericardial effusion. # urinary tract infection- the patient noted to have hematuria. a ua and urine cx were sent which grew proteus. she was treated with a 7 day course of ciprofloxacin. ---------- chronic stable issues # hypothyroidism- the patient was continued on home medications levoxyl, cytomel . medications on admission: preadmission medications listed are correct and complete. information was obtained from patient. 1. levothyroxine sodium 88 mcg po daily 2. liothyronine sodium 15 mcg po daily 3. calcium carbonate 500 mg po frequency is unknown 4. vitamin d 400 unit po frequency is unknown 5. magnesium oxide 400 mg po daily 6. psyllium 1 pkt po frequency is unknown 7. selenium sulfide dose is unknown tp frequency is unknown 8. vitamin b complex 1 cap po daily discharge medications: 1. levothyroxine sodium 88 mcg po daily 2. liothyronine sodium 10 mcg po qam 3. liothyronine sodium 2.5 mcg po qpm 4. vitamin d 400 unit po bid 5. enoxaparin sodium 80 mg sc q12h rx *enoxaparin 80 mg/0.8 ml administer 1 injection subcutaneously twice a day disp #*60 syringe refills:*1 6. calcium carbonate 500 mg po frequency is unknown 7. ciprofloxacin hcl 500 mg po q12h duration: 7 days rx *ciprofloxacin 250 mg 1 tablet(s) by mouth twice a day disp #*6 tablet refills:*0 8. filgrastim 480 mcg sc q24h duration: 10 days 9. prochlorperazine 10 mg po q6h:prn nausea rx *prochlorperazine maleate 10 mg 1 tablet(s) by mouth 6 hours disp #*60 tablet refills:*0 10. scopolamine patch 1 ptch tp once duration: 1 doses 1 patch q 72 hours. should be removed on [**10-2**] discharge disposition: home discharge diagnosis: primary diagnosis primary mediastinal large b cell lymphoma pulmonary embolism/deep venous thromboembolism secondary diagnosis hypothyroidism discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. [**known lastname 3960**], it was a pleasure participating in your care at [**hospital1 18**]. you were admitted to the hospital because you were feeling short of breath, lightheaded, with associated sweating. you were found to have a cancer in your chest ( primary mediastinal large b cell lymphoma) and a blood clot in your lungs ( pulmonary embolism). you were also found to have a clot at the site of your picc line, and the line was ultimately removed. you were started on blood thiners to treat your blood clot ( lovenox also known as enoxaparin) which you will continue to take on discharge. for you cancer you finished your first cycle of chemotherapy and will follow up with your primary oncolgoist dr. [**last name (stitle) **] at the appointments scheduled for you below. your neupogen was discontinued prior to discharge, because your white count was elevated. please discuss with dr. [**last name (stitle) **] when to resume these injections at your next visit followup instructions: department: hematology/oncology when: wednesday [**2120-10-2**] at 12:45 pm with: checkin hem onc cc7 [**telephone/fax (1) 22**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) **] campus: east best parking: [**hospital ward name 23**] garage department: hematology/oncology when: wednesday [**2120-10-2**] at 1:30 pm with: [**first name8 (namepattern2) **] [**name8 (md) **], md [**telephone/fax (1) 3961**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) **] campus: east best parking: [**hospital ward name 23**] garage [**first name8 (namepattern2) **] [**name8 (md) **] md [**md number(2) 3962**]",
25,"admission date: [**2200-6-1**] discharge date: [**2200-6-3**] date of birth: [**2122-3-19**] sex: f service: medicine allergies: no known allergies / adverse drug reactions attending:[**doctor first name 3290**] chief complaint: body pain major surgical or invasive procedure: none history of present illness: 78y/o f h/o diabetes, chronic back pain, recurrent sbo requiring multiple surgeries who presents to the ed with hypotension after reported fall. admitted to icu for monitoring of hypotension. pt was seen recently in the ed [**5-30**] for left wrist pain and itching after splinted [**5-27**] from fall-related ulnar and distal radius fractures. she had been feeling alright at home but today felt fatigue, nausea, diffuse body aches and joint aches, with subjective fevers at home. she had some mild headache but no altered mental status/confusion or neck stiffness to suggest meningitis. patient may have had another fall last night. . ed course: v/s: 97.6 109 127/74 20 95% on 2l nc. developed fever to 102 (oral). pt was noted to have a nonproductive cough. interventions: pt was given morphine at 10:30 am for total body aches. also given ctx, azithro, nebs for possible pna and 2l ivf. pt then triggered for hypotension to 85 systolic from previous pressures in 150s, moved from the periphery to the core and given an additional 2l ivf ns along with vancomycin. pt received 125mg methylpred for wheezing. flu swab sent. after total 4l sbp in low-mid 90s. . on arrival to the icu, pt noted to be extremely somnolent which had not been noted before. could barely whisper her first name and only opened her eyes for several seconds in response to sternal rub and voice commands. pt received 0.4mg narcan and immediately became more alert, crying out that she was cold and that her back was cold. denied pain. would not answer any history questions other than , did not know the year. did know that she was in the hospital and that it was [**hospital3 **]. pt was also administered another liter of ns. . spoke with pts son who states that she has become increasingly depressed although fully functional still at home. in the last year bought a cemetery plot and whenever something happens to her for example her recent wrist fracture she goes and visits the plot. . review of systems: unable to obtain fully, pt altered. son saw her day before yesterday and denies that she complained of the following or that he noted any of the following. (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: pmhx: dm, obesity, htn, asthma, oa, jejunal divertic, peritonitis, perforated viscus, chronic back pain, plantar fasciitis . pshx: ex-lap/loa, trigger finger, sbr, jujunal diverticulotomy, tah/bso, tubal ligation he surgical history began with a perforated jejunal diverticulim in [**2191**]. since that time she has required multiple exlaps, loa for sbos. social history: - tobacco: remote - alcohol: remote - illicits: none family history: non-contributory. physical exam: admission exam: vitals: t: 98.5 (tylenol in ed) bp:103/52 p:83 r:21 o2: 99%ra general: lethargic but arousable (for brief intervals) not responding verbally appropriately, does not follow commands or answer questions although oriented to her own name. heent: sclera anicteric, mmm, oropharynx clear but dry mucous membranes neck: supple, jvp not elevated, no lad lungs: diffuse rhonchorous breath sounds cv: tachycardic, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley present ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: admission labs: [**2200-6-1**] 10:25am blood wbc-12.1* rbc-3.84* hgb-11.7* hct-36.2 mcv-94 mch-30.3 mchc-32.2 rdw-12.9 plt ct-300 [**2200-6-1**] 10:25am blood neuts-83.8* lymphs-6.9* monos-5.3 eos-3.6 baso-0.4 [**2200-6-1**] 11:52am blood pt-11.8 ptt-28.8 inr(pt)-1.1 [**2200-6-1**] 10:25am blood glucose-188* urean-12 creat-0.7 na-132* k-4.3 cl-97 hco3-24 angap-15 [**2200-6-1**] 10:25am blood alt-32 ast-43* alkphos-74 totbili-0.3 [**2200-6-1**] 10:25am blood lipase-25 [**2200-6-1**] 10:25am blood probnp-136 [**2200-6-1**] 10:25am blood ctropnt-<0.01 [**2200-6-1**] 10:25am blood albumin-3.9 [**2200-6-1**] 06:35pm blood tsh-0.37 [**2200-6-1**] 10:25am blood asa-neg acetmnp-neg bnzodzp-pos barbitr-neg tricycl-neg [**2200-6-1**] 05:47pm blood type-art po2-109* pco2-35 ph-7.39 caltco2-22 base xs--2 [**2200-6-1**] 10:28am blood lactate-1.3 [**2200-6-1**] 01:37pm blood lactate-0.9 [**2200-6-1**] 05:47pm blood lactate-0.8 na-137 k-3.7 cl-108 [**2200-6-1**] 05:47pm blood freeca-1.10* brief hospital course: 78 y/o f h/o dm, multiple abdominal surgeries for sbos, oa, falls, presents with hypotension and fever, admitted to the [**hospital unit name 153**] for hypotension, found to have altered mental status. #ams - on arrival to the [**hospital unit name 153**] noted to be lethargic not responding well to commands, oriented only to name. mental status improved with one dose of narcan, making medication effect likely source of ams as patient had received morphine in ed, in addition to home morphine/oxycodone. in addition, patient had received medications during her observation stay in the emergency room just a day prior to this admission. she insists that her chronic pain medications were not the cause of her change in mental status and her hypotension, but rather that the additional medications she received in the ed during her observation stay were culprit. she insisted on being very responsible regarding her medications. as medications have worn off, patient is now awake and alert. head ct negative for subdural in the setting of fall. patient was febrile in the ed, but is now hemodynamically stable without other fevers and cxr negative for pneumonia, making infection unlikely source of ams. patient remained lucid for the remainder of the admission, and was seen to be extremely anxious to go home. #hypotension: patient with hypotension to sbp 80s in the ed (baseline sbp 110-160). bp now stable in 120??????s since admission to the icu. given blood pressure normalized following clearance of opioids, likely opioid-induced. no further evidence of infection to support sepsis as etiology. troponin x 2 negative for evidence of cardiac ischemia. systolic blood pressures started to rise to 150 at the time of discharge so patient was instructed to continue all of her home antihypertensives. #h/o asthma - pt was reportedly wheezy in ed. s/p 125mg solumedrol. lungs clear for the remainder of the admission. #h/o anxiety - holding home diazepam in setting of ams, but patient was clearly anxious to be discharged from the hospital, and insisted on repeating every detail of her history. #h/o left wrist fracture - on long acting morphine and oxycodone at home. in setting of ams and lethargy/unresponsiveness, these medications were initially held. however, these are patient's long standing medications, so she will continue to use them, as they have not caused lethargy or change in mental status in the past. vitamin d level ordered and is pending at time of discharge. #chronic back pain- patient to resume home medications on discharge medications on admission: medications: per pcp [**name initial (pre) 626**] [**2200-5-16**] medications - prescription albuterol sulfate - 2.5 mg/3 ml (0.083 %) solution for nebulization - 1 vial inhaled four times a day as needed for shortness of breath albuterol sulfate - 90 mcg hfa aerosol inhaler - 2 (two) puffs(s) inhaled q 4h for one month then qid as needed for as needed for asthma - no substitution betamethasone dipropionate - 0.05 % cream - apply [**hospital1 **] twice a day as needed for itching chloroquine phosphate - 250 mg tablet - 1 tablet(s) by mouth twice a week clonidine - 0.1 mg tablet - 1 tablet(s) by mouth twice a day clotrimazole - 1 % cream - apply to feet once a day once a day as needed for fungal infection discontinue if you experience any adverse reactions or rashes diazepam - 5 mg tablet - 1 tablet(s) by mouth qhs prn fluticasone - 50 mcg spray, suspension - 1 puff(s) each nostril twice a day for allergies/running nose fluticasone - 0.05 % cream - apply to affected area twice a day as needed for pruritis fluticasone-salmeterol [advair diskus] - 500 mcg-50 mcg/dose disk with device - 1 puff po twice a day for asthma furosemide - 20 mg tablet - 1 tablet(s) by mouth once a day for swelling and blood pressure gabapentin - 600 mg tablet - 1 tablet(s) by mouth three times a day for neuropathy glipizide - 10 mg tablet - 1 tablet(s) by mouth once a day for sugar hydroxyzine hcl - 25 mg tablet - 1 tablet(s) by mouth three times a day as needed for itching ipratropium-albuterol - 0.5 mg-2.5 mg/3 ml solution for nebulization - 1 vial inhaled three times a day lisinopril - 40 mg tablet - 1 tablet(s) by mouth once a day for blood pressure metformin - 500 mg tablet - 1 tablet(s) by mouth 2 q pm for diabetes (also called glucophage) morphine - 30 mg tablet extended release - 1 tablet(s) by mouth twice a day as needed for pain olopatadine [patanol] - 0.1 % drops - 1 drop eqch eye twice a day oxycodone - 15 mg tablet - 1 tablet(s) by mouth three times a day as needed for pain polyethylene glycol 3350 - 17 gram powder in packet - 1 packet(s) by mouth qd, as needed for hard stool pravastatin - 40 mg tablet - 1 tablet(s) by mouth at bedtime for cholesterol sertraline - 50 mg tablet - 1 tablet(s) by mouth once a day for sadness, depression also called zoloft trazodone - 50 mg tablet - 1 tablet(s) by mouth at bedtime as needed for sleep . medications - otc acetaminophen - 500 mg tablet - 1 tablet(s) by mouth three times a day as needed for pain also called tylenol aspirin - 81 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth once a day carbamide peroxide - 6.5 % drops - 3 drops(s) to right ear daily as needed to soften ear wax cholecalciferol (vitamin d3) - 1,000 unit capsule - 1 capsule(s) by mouth daily (daily) dextran 70-hypromellose - drops - 1 drop both eyes twice a day dextran 70-hypromellose [artificial tears] - drops - 1 drop ou four times a day as needed for eye irritation bedtime as needed for constipation neomycin-polymyxin-pramoxine [antibiotic + pain relief] - 0.35 %-10,000 unit-[**unit number **] mg/gram cream - apply to biopsy site tid-qid omeprazole magnesium [prilosec otc] - 20 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth once a day for acid polyvinyl alcohol - 1.4 % drops - 1 gt ou three times a day sennosides [senna] - 8.6 mg capsule - [**2-10**] capsule(s) by mouth once a day as needed for constipation - no substitution white petrolatum-mineral oil - cream - pply to feet and hands bidd as needed for dry, cracking skin discharge medications: 1. fluticasone-salmeterol 500-50 mcg/dose disk with device sig: one (1) disk with device inhalation [**hospital1 **] (2 times a day). 2. gabapentin 300 mg capsule sig: two (2) capsule po tid (3 times a day). 3. patanol 0.1 % drops sig: 1 drop ophthalmic twice a day: for both eyes. 4. clonidine 0.1 mg tablet sig: one (1) tablet po twice a day. 5. furosemide 20 mg tablet sig: one (1) tablet po once a day. 6. glipizide 10 mg tablet sig: one (1) tablet po once a day. 7. metformin 500 mg tablet sig: one (1) tablet po once a day. 8. lisinopril 40 mg tablet sig: one (1) tablet po once a day. 9. sertraline 50 mg tablet sig: one (1) tablet po once a day. 10. trazodone 50 mg tablet sig: one (1) tablet po qhs prn as needed for insomnia. 11. valium 5 mg tablet sig: one (1) tablet po once a day as needed for anxiety. 12. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation q4h (every 4 hours) as needed for dyspnea, wheezing. 13. hydroxyzine hcl 25 mg tablet sig: one (1) tablet po three times a day as needed for itching. 14. morphine 30 mg tablet extended release sig: one (1) tablet extended release po twice a day as needed for pain. 15. oxycodone 15 mg tablet sig: one (1) tablet po three times a day as needed for pain. 16. pravastatin 40 mg tablet sig: one (1) tablet po once a day. 17. polyethylene glycol 3350 powder sig: 1 pouch miscellaneous once a day. 18. ipratropium bromide 0.02 % solution sig: one (1) inhalation three times a day. discharge disposition: home with service facility: [**location (un) 86**] vna discharge diagnosis: sedation, hypotension, from medication effect discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital with sedation and low blood pressure, and this appears to have been caused by medications that you received in the emergency room for your wrist pain. your blood pressures are now normal and you are in stable condition. you may continue to take all of your home medications. followup instructions: department: [**hospital 7975**] [**hospital **] health center when: monday [**2200-6-9**] at 10:45 am with: [**name6 (md) **] [**last name (namepattern4) 8268**], md [**telephone/fax (1) 7976**] building: [**hospital1 7977**] ([**location (un) 686**], ma) [**location (un) **] campus: off campus best parking: free parking on site *dr. [**last name (stitle) **] works with dr. [**last name (stitle) 8499**]",1
26,"admission date: [**2200-9-18**] discharge date: [**2200-9-26**] date of birth: [**2122-4-12**] sex: f service: medicine allergies: iodine; iodine containing / scopolamine attending:[**first name3 (lf) 905**] chief complaint: weakness major surgical or invasive procedure: central venous line placement picc line placement history of present illness: 78 y/o f with a hx of pmr on chronic steroids, type 2 dm, chf w/ef 50%, dvt [**9-14**] who presents with a one day history of diarrhea. pt reports she woke up in the middle of the night a day ago and had diarrhea. she had six episodes throughout the course of the day and felt weak. she had no other symptoms, including nausea, vomiting, abdominal pain, fever, chills, cough, shortness of breath, chest pain, dysuria, urinary frequency, or any other complaints. no recent travel or change in eating habits. * in the ed here, she was febrile to 101, hypotensive to 88/49, tachy in the 100s. cultures were drawn and she was given levofloxacin and flagyl given the abdominal pain. her initial lactate was 2.9, she had a wbc count of 20 with a left shift and 8% bands, and her creatinine was elevated at 1.3 from 0.9 3 months ago. an abdominal ct was done to r/o an abscess (given that she's on chronic steroids) and it showed diverticulosis but no diverticulitis, as well as stable dilation of her cbd. she was given 2 liters of ivf and her lactate worsened to 4. she remained hypotensive in the 80s-90s. she was mentating and making urine throughout. at this point, because of the lactate and hypotension, she was placed on the sepsis protocol. a central line was placed, and a mixed venous sat was monitored (low 70s). she received an additional 2 liters of ns and her bp remained in the 90s. past medical history: 1. pmr, on chronic steroids, has been on methotrexate in the past 2. type 2 dm, on glucophage 3. ef 50% from cath [**2196**] (clean coronaries) 4. osteoarthritis 5. dvt [**9-14**], rx w/coumadin which was stopped one month ago 6. ugi bleed 20 years ago [**2-12**] nsaids 7. depression 8. hx extrapulmonary tb as a teenager 9. hx gallstone pancreatitis [**9-14**] 10. asthma surgical hx: - hysterectomy at age 36 for fibroids - l tkr - r knee fusion - r eye cataract surgery social history: lives at home by herself in [**hospital1 8**]. never married. has a niece who checks in on her frequently. retired nurse. no tobacco or alcohol. family history: f: died at age 89 from gastric ca. also had htn and gout. m: died at age 88 from a stroke. also had dm, htn, and arthritis. 4 siblings, all deceased: emphysema, breast ca, lymphoma, dm. physical exam: t: 99.5 bp: 88/41 p: 96 r: 19 o2 sat: 97% on ra gen: awake, alert and oriented female in no acute distress, asking for diet pepsi heent: normocephalic, atraumatic. sclerae anicteric, conjunctivae noninjected. mm dry. neck: supple. r ij in place with some oozing at line site. no palpable lymphadenopathy. lungs: mild insp crackles at the bases, diffuse expiratory wheezes cv: tachycardic, regular, ii/vi systolic murmur at lsb abd: soft, nontender, nondistended. +bs. ext: 1+ le edema, r>l. feet are cool, 1+ dp pulses bilaterally. neuro: cn ii-xii intact. strength 5/5x4 ext. pertinent results: [**2200-9-17**] 10:27pm lactate-2.9* k+-4.6 [**2200-9-17**] 10:30pm pt-13.2 ptt-21.0* inr(pt)-1.2 [**2200-9-17**] 10:30pm plt smr-normal plt count-278 [**2200-9-17**] 10:30pm hypochrom-1+ anisocyt-1+ poikilocy-normal macrocyt-normal microcyt-1+ polychrom-normal ovalocyt-occasional [**2200-9-17**] 10:30pm neuts-90* bands-7* lymphs-1* monos-2 eos-0 basos-0 atyps-0 metas-0 myelos-0 [**2200-9-17**] 10:30pm wbc-21.6*# rbc-4.69 hgb-13.3 hct-40.8 mcv-87 mch-28.4 mchc-32.6 rdw-16.4* [**2200-9-17**] 10:30pm albumin-2.8* calcium-9.1 phosphate-4.1 magnesium-1.8 [**2200-9-17**] 10:30pm lipase-16 [**2200-9-17**] 10:30pm alt(sgpt)-16 ast(sgot)-35 alk phos-107 amylase-103* tot bili-0.5 [**2200-9-17**] 10:30pm glucose-113* urea n-30* creat-1.3* sodium-144 potassium-5.0 chloride-106 total co2-26 anion gap-17 [**2200-9-18**] 03:15am lactate-4.0* [**2200-9-18**] 05:00am urine rbc-0-2 wbc->50 bacteria-mod yeast-none epi-[**3-15**] [**2200-9-18**] 05:00am urine blood-mod nitrite-pos protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-mod [**2200-9-18**] 05:00am urine color-yellow appear-clear sp [**last name (un) 155**]-1.033 [**2200-9-18**] 05:00am lactate-4.0* [**2200-9-18**] 05:57am freeca-1.05* [**2200-9-18**] 09:14am glucose-91 urea n-27* creat-1.1 sodium-144 potassium-4.0 chloride-111* total co2-18* anion gap-19 [**2200-9-18**] 09:17am lactate-2.1* ct abd: abdomen ct with intravenous contrast: two calcifications are again visualized in the right breast. there is mild atelectasis at the visualized lung bases. the liver, gallbladder, spleen, adrenal glands, and kidneys appear unremarkable. pancreatic duct is dilated throughout, unchanged compared to the previous study. there is no free fluid or peripancreatic fat stranding. small bowel and colon loops are normal in caliber without evidence of wall thickening. a clip is again noted in the inferior vena cava, related to pulmonary embolism prophylaxis. there is no free air. pelvis ct with intravenous contrast: there are diverticula in the sigmoid colon without evidence of diverticulitis. the bladder and rectum appear unremarkable. the uterus is absent. there is no free fluid. bone windows: degenerative changes are again seen in the spine. ct reconstructions: multiplanar reconstructions confirm the findings demonstrated on the axial images. value grade is 2. impression: 1. diverticulosis without evidence of acute diverticulitis. 2. stable appearance of the dilated pancreatic duct without evidence of peripancreatic inflammation. cxr: findings: ap upright portable view of the chest. the right internal jugular central venous line terminates in the inferior portion of the right atrium. it should be pulled back by at least 7 cm. there is no pneumothorax. there is persistent elevation of the left hemidiaphragm and associated left lower lobe atelectasis. the remainder of the lungs are clear. heart and mediastinal contours are stable. there is no pulmonary edema. surgical changes are noted in the right shoulder. impression: 1. central venous line malposition with tip in the right atrium, which should be pulled back by at least 7 cm. 2. stable left lower lobe atelectasis. no new pulmonary opacities to suggest pneumonia. rle u/s: no dvt brief hospital course: a/p: 78 y/o f w/pmr on chronic steroids admitted with diarrhea, fever, hypotension, elevated lactate and bandemia. * 1. presented in septic shock; adequately rescussitated in micu (code sepsis). was stable after 10 hours in micu (no pressors, just fluid rescusitation and abxs). she was transferred to a floor bed and was stable for 24 hours. she was changed from levofloxacin to zosyn for suspicion of adverse reaction to levo, having a swollen neck and wheezing. she received benadryl, pepcid ans [**last name (un) **] dose steroids were continued. . on the afternoon of [**2200-9-20**], she became confused and combative. unresponsive. an abg was drawn which revealed a ph of 7.00/30/167 with lactate of 17. she was given 3 amps of bicarb and fluids and started on heparin for potential pe (stopped after initial bolus given). a femoral line was attempted but the wire could not be threaded. she was given 1 dose of vanco and gentamycin and the zosyn was continued. repeat abg was 7.26/30/259 with a lactate of 9.6. she was transferred to the micu. . in the micu, she was found to have a hct of 22. the source of lactic acidosis was likely due to hyperperfusion from ongoing sepsis and acute bleed. given that source of sepsis was not entirely clear (dirty u/a without urine cx) and with a concearn for occult bleed, ct abd was repeated. it showed a large perihepatic bleed. no rp bleed. labs were consistent with shock liver. hepatology was consulted. in their opinion, this was aspontaneous rp bleed due to shock liver from ongoing sepsis. pt was supported with blood products and fluids. [**2-12**] bcx grew e. coli. zosyn monotherapy was continued. ct abd/pelvis revealed no other infectious sources. plan was to continue a total of 3 weeks of zosyn for bacteremia/sepsis of unclear source (likely urine). * perihepatic bleed: unclear etiology. [**month/day (2) 4338**] liver showed large perihepatic bleed (stable) and an area of intraparenchymal hemprrhage in zone 8 of liver (no active contrast extravasation; no underlying lesion). ? possibility of septic embolic event leading up to this although no obvious source as presumed uti was appropriately ttreated. pt required transfusion of several units of prbcs, since then for the next 4 days, hct remained stable. asked liver team to comment on this and they recommended f/u [**month/day (2) 4338**] abdomen in 2 weeks and to be seen in liver clinic soon after this study. 2. abnormal lft's and subcapsular bleed: likely due to shock liver as above. lfts improving. gemfibrozil held. [**month/day (2) 4338**] done with results as above. 3. lactic acidosis: resolving; cont to monitor i/os. * 4. arf: improving. u/s without hydronephrosis. renally dosing meds. 5. ?cad/chf: cath w/ clean coronaries by regional wma on lv gram and mildly depressed ef. has dm so likley has nonobstructive cad and microvasc dz. unclear why not on an [**name (ni) **]. will defer this to pcp. [**name10 (nameis) **] evidence of angina. restarted lopressor and lasix. * 6. type 2 dm: hold metformin given recent lactic acidosis, fs qid, humalog sliding scale. * 7. pmr: on home dose pf prednisone. cont tylenol #3 for pain. * 7. fen: encourage po diet. monitor uop. * 8. ppx: pneumoboots; ppi. * 9. communication: with pt. * 10. code: dnr/dni. * 11. access: picc placed; fem line d/c'ed. 12. thrush: nystatin medications on admission: methylprednisolone (dose unknown, switched from prednisone in the last 2 weeks) premarin 0.3 mg daily synthroid 125 mcg daily glucophage 500 mg [**hospital1 **] atenolol 12.5 mg daily prevacid 30 mg daily gemfibrozil [**hospital1 **] oxycontin 10 mg [**hospital1 **] tylenol #3 q6h prn vitamin a daily vitamin d daily senna colace calcium lasix 20 mg daily elavil 25 mg daily discharge medications: 1. levothyroxine sodium 125 mcg tablet sig: one (1) tablet po daily (daily). 2. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. bisacodyl 10 mg suppository sig: [**1-12**] suppositorys rectal daily (daily) as needed. 5. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 6. prednisone 5 mg tablet sig: seven (7) tablet po daily (daily). 7. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day) as needed. 8. albuterol sulfate 0.083 % solution sig: [**1-12**] inhalation q4h (every 4 hours) as needed. 9. albuterol sulfate 0.083 % solution sig: [**1-12**] inhalation q4h (every 4 hours). 10. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 11. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 12. fluticasone-salmeterol 100-50 mcg/dose disk with device sig: [**1-12**] disk with devices inhalation [**hospital1 **] (2 times a day). 13. piperacillin-tazobactam na 2.25 gm iv q6h 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 qd and prn. inspect site every shift discharge disposition: extended care facility: [**hospital3 537**]- [**location (un) 538**] discharge diagnosis: 1. e. coli sepsis/bacteremia (presumed urine source) 2. perihepatic bleed 3. asthma 4. pmr on steroids 5. diabetes discharge condition: stable; requires albuterol nebs for comfort (asthma) discharge instructions: please take all medications as directed. please take all medications as directed. please keep your appointments listed below. followup instructions: 1. please follow up with your pcp within next few weeks 1. please follow up with your pcp within next few weeks. 2. provider: [**name10 (nameis) 4338**] where: cc clinical center [**name10 (nameis) 4338**] phone:[**telephone/fax (1) 327**] date/time:[**2200-10-10**] 12:15 3. provider: [**first name8 (namepattern2) **] [**last name (namepattern1) **], md where: lm [**hospital unit name 7129**] center phone:[**telephone/fax (1) 2422**] date/time:[**2200-10-27**] 10:30 [**name6 (md) 251**] [**name8 (md) **] md [**md number(1) 910**] completed by:[**2200-9-26**]",1
27,"admission date: [**2115-8-12**] discharge date: [**2115-8-16**] date of birth: [**2049-7-11**] sex: f service: nmed allergies: patient recorded as having no known allergies to drugs attending:[**first name3 (lf) 5378**] chief complaint: status epilepticus major surgical or invasive procedure: none history of present illness: this is a 66 year old woman with a history of seizures who now presents to the ed reportedly after having four seizures since 4pm today according to her husband. she was found by ems in bed lying on her side, eyes deviated to the right with both upper extremities flexed in a tonic upward position. they were not certain as to what her lower extremities were doing. they were informed by her husband (whom i cannot reach because the phone number in the computer is out of service) that she has approximately one a month and only takes dilantin for her seizures. she was incontinent. they took her on her stretcher and she gripped the handrail and was thought to be shaking on her left arm. when she arrived to the ed the nurse [**first name (titles) 8706**] [**last name (titles) **] arm shaking with the eyes fixed right, beating quickly to the left, all of which broke with benzodiazepines, first 5mg valium given by ems and then 2mg ativan when it recurred. she has also since received 2g ceftriaxone and 1g dilantin. i was finally able to reach the husband at [**telephone/fax (1) 11437**]. [**name2 (ni) **] tells me that she has had seizures, approximately once a month and they occur more frequently when she is under a great deal of stress. she was recently diagnosed with a urinary tract infection and placed on ciprofloxacin because she was unable to go to the bathroom. she apparently was well until today at 3:30pm when she had the first of several seizures. in between each seizure she went to sleep. she denied headache, abdominal pain to him but she apparently did vomit a couple of times. her primary care physician is [**last name (namepattern4) **]. [**last name (stitle) 11438**] in [**location (un) **], ma at [**telephone/fax (1) 11439**]. past medical history: seizure disorder, hypertension, hypercholesterolemia, diabetes, mild anemia, history of hyponatremia with flurry of seizures, coronary artery bypass graft surgery [**2110**], old left pca infarct seen on old mri scan in [**2107**], left below- the-knee amputation [**2110**], recent coronary? stents put in 6 months ago at [**hospital1 756**] and women's hospital social history: she and her husband living in a nursing facility habits: not known, reportedly no smoking, alcohol, or drugs family history: unknown physical exam: t 103 bp 220/111 hr 112 rr 18 o2 sat 99% nrb general appearance: ill appearing older woman heart: regular rate and rhythm without murmurs, rubs or gallops lungs: clear to auscultation bilaterally. abdomen: soft, nontender extremities: no clubbing, cyanosis or edema skull & spine: neck is supple. mental status: the patient is sleepy, intermittently opening her eyes to voice. she does not follow commands. cranial nerves: she does not blink to threat bilaterally. there is no nystagmus in primary gaze. she is able to make horizontal eye movements. the optic discs could not be visualized because she was moving her eyes around to avoid the light. eye movements are normal, the pupils react normally to light, both directly and consensually. there appears to be a right facial droop. there is no nystagmus. sensory/motor system: there is left below the knee amputation. she withdraws all 4 extremities to pain. there is decreased tone in the right arm. reflexes: the tendon reflexes are present, symmetric and normal in the upper extremities, absent in the lower extremities. the plantar reflexes are extensor on the right. pertinent results: [**2115-8-12**] 10:27pm ck(cpk)-189* [**2115-8-12**] 10:27pm ck-mb-13* mb indx-6.9* ctropnt-1.07* [**2115-8-12**] 02:30pm glucose-149* urea n-34* creat-1.8* sodium-139 potassium-4.1 chloride-105 total co2-22 anion gap-16 [**2115-8-12**] 02:30pm ck(cpk)-224* [**2115-8-12**] 02:30pm ck-mb-19* mb indx-8.5* ctropnt-0.93* [**2115-8-12**] 02:30pm calcium-8.5 phosphate-3.2 magnesium-1.7 [**2115-8-12**] 02:30pm plt count-185 [**2115-8-12**] 02:30pm plt count-185 [**2115-8-12**] 04:35am lactate-3.2* [**2115-8-12**] 02:30pm pt-12.8 ptt-18.4* inr(pt)-1.0 [**2115-8-12**] 04:25am glucose-228* urea n-35* creat-1.9* sodium-138 potassium-3.1* chloride-98 total co2-19* anion gap-24* [**2115-8-12**] 04:25am alt(sgpt)-15 ast(sgot)-24 ck(cpk)-90 alk phos-134* tot bili-0.3 [**2115-8-12**] 04:25am ck-mb-notdone ctropnt-0.38* [**2115-8-12**] 04:25am calcium-8.8 phosphate-3.6 magnesium-1.8 [**2115-8-12**] 04:25am phenobarb-<1.2* phenytoin-15.6 [**2115-8-12**] 04:25am carbamzpn-<1.0* [**2115-8-12**] 04:25am urine hours-random [**2115-8-12**] 04:25am urine uhold-hold [**2115-8-12**] 04:25am wbc-9.6# rbc-4.07* hgb-12.9 hct-35.8* mcv-88 mch-31.8 mchc-36.2* rdw-13.2 [**2115-8-12**] 04:25am neuts-97* bands-1 lymphs-1* monos-0 eos-0 basos-0 atyps-0 metas-1* myelos-0 [**2115-8-12**] 04:25am plt count-242 [**2115-8-12**] 04:25am pt-12.8 ptt-18.0* inr(pt)-1.0 [**2115-8-12**] 04:25am urine color-straw appear-hazy sp [**last name (un) 155**]-1.016 [**2115-8-12**] 04:25am urine blood-mod nitrite-neg protein-500 glucose-neg ketone-15 bilirubin-neg urobilngn-neg ph-5.0 leuk-mod [**2115-8-12**] 04:25am urine rbc-0-2 wbc->50 bacteria-many yeast-none epi-0-2 brief hospital course: pt was initially admitted to the icu for status epilepticus. she was found to have a uti with proteus, resistant to multiple antibiotics, was treated on ceftriaxome iv for three days and did not have any adverse reactions. she has a h/o left pca/mca watershed encephalomalacia and cerebellar hypodensities on ct but has no new strokes on mri. we treated her initially on dilantin 200/100/200 and keppra 500 [**hospital1 **]. she had a stable neurologic exam with baseline disorientation to time/date. she had no further siezures and we feel that her sz were from uti giving her a metabolic derangement. we also found that the patient has a poor compliance with medications and is almost paranoid about letting people help her with her medications. initially pt had an elevation in her troponin to 1.07 and a downtrend (see lab section). cardiology has been involved. pt has had several episodes of chest pain on the floor, and has had several more ekg's showing no evidence of acute infarct. cardiology was reconsulted and recommended persantine studies, but as pt would not want to proceed with catheterization, there is no utility to pursuing this study at this time. chest pain was not felt to be cardiac in origin. medications on admission: dilantin 200/100/200, sodium bicarbonate, ativan, folate, plavix, quinine sulfate, protonix, keppra one tab twice a day (unsure what dose is), lipitor, norvasc, lasix, cipro discharge medications: 1. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po qd (once a day). 2. atorvastatin calcium 10 mg tablet sig: one (1) tablet po qd (once a day). 3. levetiracetam 500 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 4. aspirin 325 mg tablet sig: one (1) tablet po qd (once a day). 5. phenytoin sodium extended 100 mg capsule sig: two (2) capsule po bid (2 times a day). disp:*120 capsule(s)* refills:*0* 6. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. norvasc 10 mg tablet sig: one (1) tablet po once a day. 8. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. 9. lorazepam 1 mg tablet sig: one (1) tablet po four times a day. 10. quinine sulfate 260 mg tablet sig: one (1) tablet po at bedtime. 11. sodium bicarbonate 650 mg tablet sig: one (1) tablet po three times a day. 12. lorazepam 2 mg tablet sig: one (1) tablet po daily (daily). 13. toprol xl 100 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po once a day. disp:*30 tablet sustained release 24hr(s)* refills:*2* 14. lisinopril 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 15. imdur 30 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 with service facility: all care vna of greater [**location (un) **] discharge diagnosis: 1. seizure disorder 2. urinary tract infection 3. troponin leak 4. peripheral vascular disease 5. diabetes 6. hypercholesterolemia 7. anemia 8. hypertension discharge condition: stable, tolerating an oral diet, afebrile. discharge instructions: please take your medications as prescribed. please get your dilantin level checked in one week at your doctor's office (no appointment needed). please keep your follow up appointments. call your doctor or return to the emergency department if you have recurrent seizures, persistent headaches, changes in your vision, fevers, chills, nausea, vomiting, chest pain or pressure, shortness of breath, incontinence of bowel or bladder, or any other symptoms concerning to you. followup instructions: please keep the following appointments: 1. [**hospital 875**] clinic with dr. [**first name4 (namepattern1) **] [**last name (namepattern1) 2442**]. please call [**telephone/fax (1) 2928**] and update your insurance information with the receptionist. if you have [**hospital **] [**hospital **] health care you will need to get your doctor to give you a referral for this appointment (you may want to reschedule it for later if that is the case). provider: [**name10 (nameis) **] [**name11 (nameis) **], md where: [**hospital6 29**] neurology phone:[**telephone/fax (1) 3506**] date/time:[**2115-8-28**] 2:30 2. vascular surgery appointment with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **]: wednesday [**2115-9-4**] at 11:00am. [**last name (namepattern1) **]. [**location (un) 6332**] suite b. [**telephone/fax (1) 1784**]. provider: [**name10 (nameis) **],[**first name3 (lf) **] d. vascular surgery where: vascular surgery date/time:[**2115-9-4**] 11:00 [**first name11 (name pattern1) **] [**last name (namepattern4) 5379**] md, [**md number(3) 5380**]",0
28,"admission date: [**2169-4-5**] discharge date: [**2169-4-12**] date of birth: [**2096-12-16**] sex: f service: medicine allergies: penicillins / pneumovax 23 attending:[**first name3 (lf) 317**] chief complaint: gib major surgical or invasive procedure: colonoscopy history of present illness: 72 year old female with history of cad, cva, and siezure disorder presents to ed after witnessed seizure activity. daughter said pt slumped in chair, was nonresponsive, had right sided facial droop, and was diaphoretic. she was post-ictal afterwards. pt has history of had seizure disorder secondary to stroke in [**2164**]. prior to neuro event patient c/o crampy lower abd pain, after eating lunch. ems called, initially vitals bp 90/40s, diaphoretic, postictal. c/o crampy abd pain, having to go to bathroom in ambulance. in [**name (ni) **] pt had 3 bed pans of brbpr. bp 160s-170s, pulse 50s (beta blocked), mentating well. no cp, no sob. complaining of intermittent crampy lower abdominal pain. received 300 ns, dilantin 500 mg iv, protonix 40 mg iv, and was ordered for a head ct (neg). she had 750 cc ng lavage which was all negative. no n/v/d, no melena prior to this. she was admitted to the micu, where she received several liters ns, changed to dilantin, underwent colonoscopy. past medical history: seizures [**12-21**] hemorrhagic stroke, cad s/p cabg, alzheimer's, subtotal gastrectomy [**2158**] secondary to nhl (causing b12 def), cva, tia, htn, hyperlipidemia, b12 deficiency, hypothyroidism social history: daughter is hcp #[**telephone/fax (1) 12955**], remote smoking, no etoh, no drugs, lives on her own, family is looking for [**hospital1 1501**]. physical exam: temp 99.8/100.1 at 4pm bp 125/65 (100's-130's/40s-60s) hr 85 (60s-80s) rr 17 (14-26) i/o: 1800/1530 (los +5499) gen: nad pleasantly demented female heent: ncat, perrl, eomi, mmm, no nystagmus cv: rrr s1 s2 ii/vi sm at lsb no r/g resp: ctabl no r/r/w abd: soft, +nabs, llq tenderness to mild palp, no r/g, nd ext: no cyanosis clubbing or edema neuro: cn 2-12, aaox3, strength 5/5 b/l ue and le and sensation to lt grossly intact, 2+ dtr biceps (not able to elicit at knees) skin: warm, dry pertinent results: [**2169-4-5**] 03:25pm blood wbc-8.0# rbc-4.09* hgb-13.3 hct-39.2 mcv-96 mch-32.6* mchc-34.0 rdw-12.8 plt ct-169 [**2169-4-5**] 03:25pm blood neuts-76.0* lymphs-17.0* monos-5.6 eos-1.2 baso-0.3 [**2169-4-5**] 03:25pm blood pt-12.7 ptt-24.8 inr(pt)-1.1 [**2169-4-5**] 03:25pm blood glucose-142* urean-21* creat-1.2* na-138 k-3.7 cl-104 hco3-23 angap-15 [**2169-4-5**] 03:25pm blood alt-16 ast-23 ck(cpk)-128 alkphos-69 amylase-197* totbili-0.3 [**2169-4-5**] 03:25pm blood lipase-54 [**2169-4-5**] 03:25pm blood calcium-8.8 phos-3.9 mg-2.3 [**2169-4-7**] 06:35am blood triglyc-39 hdl-54 chol/hd-1.9 ldlcalc-38 [**2169-4-5**] 03:25pm blood carbamz-5.7 [**2169-4-6**] 04:45am blood lactate-2.3* . micro: negative blood and stool culture . tagged rbc scan [**2169-4-5**]: focus of tracer accumulation in the pelvis does not change over 90 minutes of imaging and is most likely located in the rectum. this finding can be seen with hemorrhoids. no site of active hemorrhage is seen in the small or large bowel. if clinically indicated, additional imaging can be performed with a 12 hour delay. . cth [**2169-4-5**]: : no evidence of acute intracranial hemorrhage. unchanged right frontal encephalomalacia and evidence of chronic microvascular ischemia. . [**2169-4-5**] ekg: sinus bradycardia at 53 bpm with first degree a-v block (pr 220) left atrial abnormality, long qtc interval 463ms, extensive st-t changes are nonspecific since previous tracing of [**2165-10-29**], no significant change . colonoscopy [**4-6**]: erythema, friability and ulceration in the sigmoid colon compatible with likely ischemic colitis. erythema in the rectum. otherwise normal colonoscopy to sigmoid colon . cta abd w&w/o c & recons [**2169-4-7**]: 1) diffuse mild-to-moderate bowel wall edema, particularly in the rectosigmoid region, with suggestion of inflammation in the sigmoid, but without discrete fluid collection. this is consistent with the clinical diagnosis of ischemic colitis, particularly in the rectosigmoid region. no evidence of obstruction or perforation. 2) patent major branches, with vascular calcifications. patency of superior mesenteric vein and portal vein also demonstrated. no intraluminal filling defects identified, however, ischemia is not definitively excluded on the basis of this study. 3) cyst in right kidneys; low-density lesions in left kidney and liver, too small to fully characterize, but also probably representing cysts. 4) bilateral small pleural effusions. brief hospital course: a/p: 72 y/o f w/dementia, cad, cva, p/w seizures and brbpr: 1. gi bleed: she was followed by gi and surgery and had a tagged rbc scan which was consistent with a rectosigmoid bleed. she then underwent colonoscopy which showed ischemic colitis in that area while in the micu. she was placed on prophylactic gi antimicrobial coverage while in the icu. she did not require a blood transfusion and as she was stable, was transferred after colonoscopy to the floor. on the floor, ct angiogram of the abdomen was done to evaluate her bowel wall and vasculature was done as she was still having pain. this was again consistent with rectosigmoid ischemic colitis with significant bowel wall edema. her abdominal pain slowly resolved. her hematocrit did trend down slowly from 37-39 on the day of admission to 32 at discharge but she did not meet our criteria for blood transfusion. she has a baseline b12 deficiency for which she takes supplements, however, this anemia was thought to be from a slow gi ooze. her reticulocyte count was at 1.6. her diet was slowly advanced, and she tolerated this without difficulty. we placed her on a low dose aspirin instead of her prior full strength, weighing the risk of bleeding with the opposing risk of her significant underlying ischemic arterial disease. her antibiotics were discontinued. she was started on protonix iv and discharged on po protonix for gi prophylaxis. she will need a repeat colonsocopy or flexible sigmoidoscopy in [**4-26**] weeks to assess for complete resolution. . 2. seizures: head ct ruled out bleed and she had no residual neurologic defects. given her history, and as she had a witnessed seizure she was loaded with iv dilantin 500 iv x1, then placed on standing dilantin iv while she was npo. once she was eating, tegretol was restarted and once the tegretol level was at goal ([**3-8**]), the dilantin was discontinued. her nightly tegretol dose was increased. 3. arf: her creatinine peaked at 1.2 at admission. this resolved to baseline ~0.8, with hydration and was thought to be secondary to prerenal azotemia. . 4. cad: her asa was initially held, and her beta blocker was initially dosed at 1/2 her home dose in the micu. the beta blocker was eventually resumed at her full dose but her asa was restarted at 81mg instead on the floor, as discussed above. we continued her lisinopril and resumed her statin at transfer to the floor. . 5. ppx: maintained on protonix iv and then switched to po, pneumoboots . 6. adverse pneumococcal vaccine reaction: after receiving the pneumococcal vaccine, per hospital protocol for all patients in her age group who have not been previously immunized, the patient developed erythema, induration, and pain at the injection site in her right deltoid consistent with an adverse vaccine reaction. prior to receiving this vaccination, the patient's daughter and hcp had specifically been questioned about her mother's vaccination history and she denied that her mother had received the pneumoccocal vaccine in the past. the patient received standing tylenol, and prn ibuprofen, and ice packs for pain with improvement. the adverse reaction was duly reported to appropriate hospital and federal authorities. . 7. hypothyroidism: we continued her home dose of synthroid. . 8. alzheimers: she was mostly pleasantly demented, but sundowned with agitation and wandering requiring frequent redirection. her living situation was discussed with her children, and per her daughter and hcp, her children will personally provide 24 hour monitoring for her at the patient's home, with eventual plans to find a [**hospital1 1501**]. they deffered our offer to help provide them with this service at discharge. she was continued on exelon once taking po's. . 9. glaucoma: she was continued on her home medications . 10. code: full . 11.communication: daughter [**first name8 (namepattern2) 501**] [**last name (namepattern1) **] [**telephone/fax (1) 12956**] (h) [**telephone/fax (1) 12957**] (c) [**first name4 (namepattern1) 892**] [**last name (namepattern1) 12958**] cell [**telephone/fax (1) 12959**] (cell) son [**name (ni) **] [**name (ni) **] [**telephone/fax (1) 12960**] cell daughter [**telephone/fax (1) 12961**] (w) medications on admission: tegretol 200"", lisinopril 20', b12 1000', toprol xl 50', ec asa 325', synthroid 25', exelon 1.5"", lipitor 40', traratan 1gtt ou, azopt 1gtt tid, mvi, calcium "" * meds on transfer to floor: levofloxacin 500 mg iv q24h ischemic colitis 1000 ml d5 1/2ns continuous at 125 ml/hr for [**2163**] ml acetaminophen [**telephone/fax (1) 1999**] mg po q4-6h:prn pain azopt *nf* 1 % ou tid metoprolol 12.5 mg po bid metronidazole 500 mg iv q8h ischemic colitis pantoprazole 40 mg iv q24h exelon *nf* 1.5 mg oral [**hospital1 **] phenytoin 150 mg iv q8h levothyroxine sodium 12.5 mcg iv discharge medications: 1. brinzolamide 1 % drops, suspension sig: one (1) gtt ophthalmic tid (): ou. 2. rivastigmine tartrate 1.5 mg capsule sig: one (1) capsule po bid (). 3. levothyroxine sodium 25 mcg tablet sig: one (1) tablet po daily (daily). 4. atorvastatin calcium 40 mg tablet sig: one (1) tablet po daily (daily). 5. carbamazepine 200 mg tablet sig: one (1) tablet po qam (once a day (in the morning)). 6. metoprolol succinate 50 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). 7. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 8. 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* 9. tegretol 200 mg tablet sig: 1.5 tablets po at bedtime: 1 and 1/2 tablets every evening. disp:*60 tablet(s)* refills:*0* 10. tylenol 325 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain for 2 days: as needed for r arm pain. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: [**company 1519**] discharge diagnosis: ischemic colitis lower gastrointestinal bleed blood loss anemia seizure adverse reaction to pneumovax coronary artery disease, s/p cabg hypothyroidism discharge condition: stable and improved with improved abdominal tenderness. stable hemtocrit for nearly 1 week, tolerating regular diet. discharge instructions: please seek immediate medical attention if you experience further episodes of blood in your stool, or have worsening abdominal pain, or if you experience fever, shaking chills, chest pain, shortness of breath, or other symptoms concerning to you. it is very important that you follow up with gastroenterology (see below). continue to take your medications as directed. we recommend that you increase you continue taking your usual 200mg tegretol every morning (1 tablet), but increase your tegretol dose slightly in the evening --you should now take 300mg (1 and [**11-20**] tabs). your aspirin dose has been decreased to 81mg/day (a baby aspirin). [**name2 (ni) **] have also been started on an medication called protonix for reducing stomach acid (reflux). continue to apply ice packs to your right arm to reduce the inflammation from the vaccine, and take tylenol as needed for pain. the redness and pain should resolve over the next [**11-20**] days. please phone your pcp if the redness and pain in the right arm has not resolved by friday. please do not drive or use the stove. followup instructions: provider: [**first name8 (namepattern2) **] [**first name8 (namepattern2) 177**] [**last name (namepattern1) **], m.d. where: [**hospital6 29**] neurology phone:[**telephone/fax (1) 1694**] date/time:[**2169-4-27**] 9:30 you have an appointment with dr. [**first name4 (namepattern1) **] [**last name (namepattern1) **], m.d., [**2169-5-1**] 12:30 in the [**hospital unit name 12962**] suite, which is located at [**location (un) 12963**]. please phone:[**telephone/fax (1) 1983**] with questions about your appointment. please follow up with your pcp, [**last name (namepattern4) **]. [**last name (stitle) 311**] within the next [**11-20**] weeks. call [**telephone/fax (1) 1713**] to make an appointment.",1
29,"admission date: [**2200-5-2**] discharge date: [**2200-5-3**] date of birth: [**2130-6-6**] sex: m service: medicine allergies: penicillins attending:[**first name3 (lf) 2297**] chief complaint: penicillin desensitization major surgical or invasive procedure: penicillin desensitization history of present illness: 69 year old male with a past medical history of prostate cancer, peripheral neuropathy, osteoarthritis, secondary polycythemia from sleep apnea and syphilis. per his records he was first diagnosed with syphilis back in [**2187**] when at that time his rpr was noted to be "">1:4"" with a positive treponemal test. at that time he received 2 im injections of pcn, but reportedly developed a rash after the second injection so he never completed the therapy. the next rpr assessment we have after that was in [**2195**] at which time his titer was 1:8. after that it has been persistently in the 1:4 range since early [**2197**]. in [**2198-11-9**] he was treated with doxycycline for 28 days as second line treatment for late latent syphilis. he also had a lumbar puncture during that time period in [**month (only) 404**] [**2198**] (he was also getting a workup with neuro for his peripheral neuropathy). he had no significant pleocytosis in his csf and his vdrl was negative. his rpr was rechecked on [**2200-3-24**] and it is still reactive at 1:4. he was admitted to the micu for penicillin desensitization as his rpr was still reactive when last checked. his review of systems was negative for chest pain, shortness of breath, abdominal pain, changes in bowel habits, fevers, chills, rashes. he reported arm and leg ""numbness and tingling"" that has been persistent for one year. he denies back pain, saddle anesthesia, bowel incontinence. past medical history: +ppd from bcg vaccine polycythemia [**doctor first name **] prostate ca dm diet controlled oa depression neuropathy osa (does not tolerate bipap) syphillis social history: rare etoh, no tob denies ivdu, sexually active originally from [**country **], married but separated from his wife family history: nc physical exam: vs: t 98.0, hr 55, bp 128/69, 97%ra, 19 gen-nad, lying in bed comfortably cv-rrr, s1, s2 no m/r/g pulm-ctab abdomen-soft, nt, +bs extremities-no edema pertinent results: [**2200-5-2**] 09:23pm blood wbc-7.2 rbc-5.54 hgb-14.2 hct-45.3 mcv-82 mch-25.6* mchc-31.3 rdw-15.4 plt ct-277 [**2200-5-2**] 09:23pm blood pt-18.1* inr(pt)-1.7* [**2200-5-2**] 09:23pm blood plt ct-277 [**2200-5-2**] 09:23pm blood glucose-124* urean-17 creat-1.1 na-142 k-3.8 cl-107 hco3-26 angap-13 brief hospital course: mr. [**known lastname 14517**] is a 69 yo male with late latent syphilis with a penicillin allergy, admitted to the micu for penicillin desensitization . 1) syphilis: patient with a persistently reactive rpr, now admitted for penicillin desensitization per protocol. he received escalating doses of penicillin q 30 minutes x 7 doses. his last dose of protocol will be followed by penicillin 2.4 million units im q week x 3 weeks. patient to maintain blood levels of pcn between im doses with oral pcn 500 mg [**hospital1 **] at discharge, he will f/u in [**hospital **] clinic on [**5-9**] for next im dose epinephrine, diphenyhydramine, ibuprofen prn adverse reaction, which did not occur. the patient tolerated the desensitization well and was discharged the following morning. . 2) atrial flutter: was in nsr on telemetry for the duration of his hospitaliation. he is anticoagulated on coumadin, and was in his target inr [**1-12**]. he was rate controlled on his home dose of metoprolol. . 3) ppx: none, as he is anticoagulated on coumadin. . 4) fen: he was npo until after first dose of penicillin, then cardiac diet. . 5) code statu: full code. medications on admission: metoprolol 50 mg [**hospital1 **] percocet 5/325 [**hospital1 **] warfarin 5 mg daily discharge medications: 1. warfarin 2.5 mg tablet sig: three (3) tablet po hs (at bedtime). 2. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 3. penicillin v potassium 500 mg tablet sig: one (1) tablet po twice a day for 2 weeks. [**hospital1 **]:*28 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: penicillin desensitization for treatment of latent syphillis atrial fibrillation prostate cancer secondary polycythemia discharge condition: stable, afebrile, good po intake discharge instructions: you were admitted to the micu for penicillin desensitization. the complete series of penicillin doses were administered without event. you received an intramuscular dose of penicillin at the end of the series. you will need to take penicillin 500mg by mouth twice daily for two weeks. please continue to take your medications as prescribed. call your doctor or go to the er if you have any shortness of breath, dizzyness, rashes, swelling, wheezing, chest pain, or any other concerning symptoms. it is important that you follow up as outlined below. followup instructions: dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 14518**] office will contact you regarding an appointment you will have on friday [**5-9**] you should follow up with your pcp [**last name (namepattern4) **]. [**first name8 (namepattern2) **] [**last name (namepattern1) 13959**] [**telephone/fax (1) 250**] within two weeks completed by:[**2200-5-11**]",0
30,"admission date: [**2177-6-5**] discharge date: [**2177-6-9**] date of birth: [**2098-1-16**] sex: m service: medicine allergies: no known allergies / adverse drug reactions attending:[**first name3 (lf) 10593**] chief complaint: pain, falls, failure to thrive major surgical or invasive procedure: none history of present illness: patient is a 79 year-old russian speaking gentleman with h/o melanoma, left lung mass nos (refused biopsy) htn, copd, presenting from home with worsening pain in neck and shoulders, confusion, and falls. patient has presumed lung malignancy, which was diagnosed in [**9-/2176**], however, diagnosis has not been confirmed as patient refuses to have lung biopsy. over the past few weeks patient has had increasing neck and shoulder pain and has had his fentanyl patch dose increased. his daughter noted he was less active than he usually is at home, but today she felt his mental status was back to baseline. he fell several times yesterday. today she discussed this with his primary care physician, [**name10 (nameis) 1023**] felt he needs to be in the hospital. as per daughter patient had no fever, chest pain, shortness of breath, abdominal pain, nausea, vomiting. she thinks patient has had recent weight loss vitals in the er: 97.2 76 128/60 16 99% ra. he had ct head and c-spine showing no acute fracture. he had a cxr showing known cavitary lung lesion. he was given morphine 2.5mg iv with improvement in his pain; he also received 2l ivf, zofran and clindamycin for ? lung abscess. he also received 2l ivf for hypercalcemia. patient was originally admitted to omed service, but while in the ed he converted from sinus rhythm to atrial fibrillation with rapid ventricular response. patient initially had hr in 160s. he received 15 mg iv diltiazem and his blood pressure dropped to systolic bp of 80. he reecived an additional 1l ns and his sbp improved to 110s. he was started on diltiazem gtt and transferred to icu. on arrival to the micu, patient denies chest pain and shortness of breath. his shoulder and neck pain are well controlled as long as he does not move. he endorses recent 12 pound weight loss. no fevers or chills. no nausea, abdominal pain. no cough. review of systems: (+) per hpi (-) denies fever, chills, night sweats. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies rashes or skin changes. past medical history: oncology history 79-year-old man with a history of copd and a pet avid left upper lobe nodule that has has grown since [**2173**], in the setting of diffuse lad. mr. [**known lastname 14535**] has had multiple conversations with several pulmonary and oncology providers in the last several years recommending tissue biopsy and bone marrow biopsy; but he refused on multiple occasions. noted to have lad in [**2172**]; at that time heme-onc was concerned for primary lung cancer versus a potential lymphoma, less likely melanoma, and recommended a bone marrow biopsy and a surgical biopsy, both of which mr. [**known lastname 14535**] declined. . imaging revealed growth of the spiculated lul nodule [**2172**]-[**2175**] to 2.4 cm, with osteolytic lesion in t5, t6, and posterior sixth left rib thought to be likely mets. on [**2176-8-14**] cxr left upper lobe lung nodule has grown to nearly 7 cm, abuts the anterior surface of the left hilus; he refused biopsy again so his pulmonologist obtained sputum sample.on [**2176-8-28**] sputum cytology revealed highly atypical squamous cells suspicious for squamous cell carcinoma. the patient has refused biopsy and therefore is not eligible for any potential treatments for this presumed malignancy past medical history: melanoma excised from his right thumb removed in [**2172**], no pathology report copd bullous skin disease followed by dermatology htn cva s/p r cea social history: lives alone. has involved daughter - [**name (ni) **] [**telephone/fax (1) 14536**]. quit smoking 13 years ago, 40 + pack years family history: noncontributory physical exam: admission exam: vitals: 98.1, 159, 92/57, 22, 91% on ra general: alert, awake, cachetic appearing elderly gentleman, comfortable, in no acute distress. heent: temporal wasting, sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: tachy, irregular, s1, s2 lungs: diminished breath sounds on left, diffuse rhonchi abdomen: scaphoid abdomen, + bs, soft, non-tender, non-distended gu: foley catheter ext: thin extremities, no clubbing/cyanosis/edema neuro: cnii-xii grossly intact, 5/5 strength upper/lower extremities discharge exam: o: w 103.8 pounds t 98 bp 114/77, 71, 18, 99ra general: alert, awake, wasted appearing elderly gentleman in nad, heent: mmm, oropharynx clear, eomi, perrl neck: supple, jvp 6cm, no lad cv: regular, nl s1, s2, [**3-25**] crescendo murmur heard best at rusb, and left lower sternal border radiating to the axilla. lungs: decreased rhonchorous breath sounds on the left throughout compared to the right. scattered rhonchi on the right. abdomen: scaphoid abdomen, + bs, soft, non-tender, non-distended gu: foley catheter ext: thin extremities, 2+ edema neuro: cnii-xii grossly intact, 5/5 strength upper/lower extremities pertinent results: admission labs: [**2177-6-5**] 06:00pm blood wbc-3.7* rbc-3.02* hgb-8.3* hct-27.5* mcv-91# mch-27.3 mchc-30.0* rdw-19.0* plt ct-110* [**2177-6-5**] 06:00pm blood neuts-64.8 lymphs-24.3 monos-4.5 eos-5.9* baso-0.4 [**2177-6-6**] 12:04am blood pt-13.7* ptt-34.8 inr(pt)-1.3* [**2177-6-5**] 06:00pm blood glucose-114* urean-43* creat-1.9* na-139 k-4.5 cl-106 hco3-24 angap-14 [**2177-6-6**] 12:04am blood ck-mb-1 ctropnt-<0.01 [**2177-6-6**] 12:04am blood ck(cpk)-17* [**2177-6-5**] 06:00pm blood calcium-12.1* phos-2.4* mg-1.9 [**2177-6-6**] 12:04am blood tsh-3.1 [**2177-6-5**] 06:09pm blood lactate-2.4* [**2177-6-6**] 12:16am blood lactate-1.2 relevant labs: [**2177-6-6**] 12:04am blood ck-mb-1 ctropnt-<0.01 [**2177-6-7**] 07:30am blood ctropnt-<0.01 probnp-6616* [**2177-6-6**] 12:04am blood ck(cpk)-17* [**2177-6-6**] 12:04am blood albumin-2.8* calcium-10.7* phos-2.3* mg-1.7 [**2177-6-8**] 07:40am blood calcium-10.5* phos-2.7 mg-1.6 [**2177-6-6**] 12:04am blood tsh-3.1 [**2177-6-7**] 07:30am blood pth-7* [**2177-6-7**] 07:30am blood cortsol-19.7 [**2177-6-8**] 08:38am blood lactate-1.5 discharge labs: [**2177-6-8**] 07:40am blood wbc-4.8 hct-30.1* [**2177-6-9**] 05:25am blood glucose-81 urean-29* creat-1.3* na-137 k-4.0 cl-105 hco3-24 angap-12 [**2177-6-9**] 05:25am blood calcium-9.9 phos-2.3* mg-1.5* microbio: urine culture negative blood culture x 2: no growth to date mrsa screen ([**6-6**]): negative studies: head ct w/o contrast ([**6-5**]): impression: no acute intracranial process. prior right frontoparietal infarct. spine ct w/o contrast ([**6-5**]): impression: 1. no acute cervical fracture or malalignment. 2. multilevel severe degenerative changes of the cervical spine as detailed above. cxr ([**6-5**]): findings: pa and lateral radiographs of the chest demonstrate a previously 5.8 x 3.6 cm left upper lobe lung mass, now measuring 8.7 x 6.5 cm with interval cavitation and a new air-fluid level, which presumably represents a cavitated bronchogenic carcinoma with necrotic contents. superimposed infection cannot be excluded. this lesion abuts the anterior left hilus. no pleural effusion or pneumothorax is detected. the cardiac silhouette is normal in size. the mediastinal and hilar contours are within normal limits. the aortic knob is partially calcified without dilatation. cxr ([**6-7**]): impression: ap chest compared to [**6-5**]: slight increase in the heart size and heterogeneous opacification at the lung bases could be due to dependent edema, but raises more concern for pneumonia. the large cavitated mass in the left upper lobe contains a fair amount of fluid. there is the possibility of internal aspiration. no pneumothorax or appreciable pleural effusion is present. echo ([**6-6**]): there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis (valve area 1.2-1.9cm2). trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is a very small pericardial effusion. there are no echocardiographic signs of tamponade. brief hospital course: patient is a 79 year-old gentleman with history of melanoma, presumptive squamous cell lung cancer with cxray revealing enlargening cavitated bronchogenic carcinoma with necrotic contents, and known osteolytic and osteoblastic lesions in the t-spine most likely from metastases presenting with pain, malaise, and falls at home, transferred to icu for a. fib with rvr which resolved with amiodarone. # altered mental status/encephalopathy: pt's mental status reportedly worsened in the setting of having his fentanyl patch increased from 25mcg to 50 mcg. moreover, the patient was found to be hypercalcemic and hypotensive on presentation. all three factors likely resulted in his ams, with resolution after decrease of his fentanyl patch, treatment and resolution of his hypercalcemia, and discontinuation of his home blood pressure medications. the patient should refrain from having increased fentanyl patch doses. infectious work-up was negative. # atrial fibrillation: patient with no known history of atrial fibrillation, developed a. fib with rvr and rate related ekg changes. precipitant unclear, but possibly etiology includes chronic disease (pt with h/o htn), pulmonary disease (patient with known copd), irritation of left atria from left lung mass, and echo revealing mild lvh, mild mr and as, so patient is good substrate. patient with rate related ekg changes that went away with better rate control. no chest pain, no dyspnea. cardiac markers normal and tsh wnl. in er was started on diltiazem gtt but became hypotensive so was admitted to the micu and started on an amiodarone gtt with a loading dose. rates better controlled with this but bp still low so amio stopped on am of [**6-6**] and pt returned to nsr. echo with mild as and small pericardial effusion without tamponade (likely malignancy related). given the patient's goals of care and falls at home, anticoagulation was not pursued. the patient's care is focused on comfort. the patient may continue his aspirin 325 mg. # hypotension: patient initially admitted to the micu for hypotension (and afib with rvr) which seemed to have developed in the setting of starting a diltiazem drip. responded to ivf but reocurred later with amiodarone drip. given more fluids and bp fine although low once amio/dilt were stopped. did not require pressors during icu stay. the patient was transferred to the floor. his blood pressures were within normal limits throughout his stay off the multi-drug hypertension regimen he was on at home. the patient states he takes too many medications, does not want to take htn medications, and his blood pressures were persistently in the 100s-140 range. he states that he used to have sbps in the 200s and felt fine. he should not be treated for his hypertension unless he requests it, becomes symptomatic, or sbps>200. initiating medications for htn should be discussed with the patient. am cortisol level wnl. # pain: patient with increasing pain of his shoulders and neck, receiving increasing doses of fentanyl patches without adequate relief. pain possibly secondary to malignancy. no evidence of fracture on ct c-spine. started on standing tylenol and contact[**name (ni) **] pcps office who confirmed home fentanyl patch had recently been uptitrated to 50mcg/hr q72hrs. rn at pcps office said that patient had increasing issues with confusion and falls on this higher dose and they were concerned that it was too much narcotic for him. in micu pt placed on fentanyl patch at 25mcg/hr and given prn oxycodone for breakthrough. pain remained reasonably well controlled. given the patient's desire to avoid confusion and his adverse reaction to higher doses of fentanyl beyond his current dose of 25 mcg/hr, the patient was placed on standing tylenol and a lidocaine patch. he should also be given ibuprofen 200-400 mg q4-6h prn for pain before being given oxycodone as his renal function tolerates. notably, the patient's focus is on having clear mentation over pain control, so care should be taken before administering the low dose opiates. #cavitary lung mass most likely from squamous cell carcinoma - pt with history of melanoma but the lung mass appears to be primary squamous cell lung carcinoma. the patient has past sputum cytology with highly atypical squamous cells suspicious for squamous cell carcinoma which in setting of appearence on imaging and hypercalcemia is most consistent with lung cancer. the diagnosis and stage are unknown because the patient refuses biopsy and further work-up. these have been clearly stated in his records here as well as via discussion with the patient and his family on this admission. palliative care engaged in open discussion with patient and confirmed his goals of care. the patient understands the potential for his course of disease to worsen. the patient requests to be dnr/dni with plans for no aggressive care and focus on comfort and quality of life. # hypercalcemia: patient with elevated calcium to 12.3 (corrected ca2+=13.1) and low phos. patient with known lytic and blastic lesions in thoracic spine. pt was given ns for this with improvement. a pth was appropriately low. the patient was given pamidronate 60 mg on [**6-7**] with improvement in calcium, 9.9 on discharge. pamidronate can be repeated as needed at least a week after initial dose. # acute kidney injury: creatinine increased to 1.9, up from most recent baseline of 1.2. likely hypovolemic secondary to poor po intake. creatinine improved with fluids. the patient was briefly diuresed for his lower extremity edema which resulted in a rise in his creatinine from 1.4 to 1.6. subsequent diuresis was held with improvement of his creatinine to 1.3 at discharge. the patient is very volume sensitive/preload dependent likely from his diastolic dysfunction from lvh and aortic stenosis. thus, if diuresis is initiated for his swelling, it should be done carefully and gingerly with close eye on renal function. # acute on chronic diastolic chf: patient with 2+ swelling of lower extremities. there is likely an element of decreased oncotic pressure as well given the patient's low albumin. patient's bnp was 6600 and echo revealed mild lvh, mr, and as, and mild pulmonary artery systolic hypertension. lvef was well preserved. the patient was tried on two doses of iv lasix with improvement in volume status but worsened renal function. the patient is likely quite preload dependent, and thus if diuresis is given, it should be gently. #hypertension, benign: patient with history of poorly controlled hypertension on six anti-hypertensives. no evidence of hypertension here. pt with excellent blood pressure control despite all medications being discontinued. patient states he previously had sbps in 200s without any symptoms and not on medications. he does not wish to take any htn meds and wants to keep his medical list simple. #copd: patient with 40 pack year smoking history and history of copd, but no dyspnea, no wheezing. continued on homoe spiriva #cva s/p r cea: continue aspirin and lipitor #code status: dnr/dni - emphasis on quality of life and limiting procedures. future hospitalizations should be discussed with patient. transitional: 1) the patient's priority is to maintain a clear mental status. as such, we have started ibuprofen in order to help with pain without using opiates, but the patient's renal function should be monitored carefully with nsaid use. 2) the patient also wants his pain well controlled, but is more concerned about maintaining a clear mental status 3) pamidraonte was given here on [**6-7**] for osteolysis of his spine from his malignancy. it can be retreated as needed as long as it is 7 days after previous dose 4) the patient states that he would like discussion before hospitalization in the future. he may not want to be hospitalized depending on the situation 5) the patient states he does not want to go home. he would feel more comfortable with people taking care of him. he currently lives alone. after rehab, there will need to be ongoing discussion with patient and family about where he should go, as he feels that he cannot take care of himself. he currently lives alone at home, with nurses that come just a few times a week. 6) notable labs on last check: hct 30.1, bun 29, cr 1.3. medications on admission: - med list confirmed with pcp office am of [**6-6**]: -> doxazosin 4mg daily -> lipitor 10mg daily -> asa 325mg daily -> clonidine 0.3mg xr daily -> fentanyl patch 50mcg/hr q72hrs (recently uptitrated at home and patient had been confused ever since this increase) -> nifedipine xl 120mg daily -> labetalol 1000mg [**hospital1 **] -> hctz 50mg daily -> enalapril 10mg [**hospital1 **] discharge medications: 1. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 2. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 3. acetaminophen 500 mg tablet sig: two (2) tablet po tid (3 times a day). 4. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 5. oxycodone 5 mg capsule sig: 0.5-1 capsule po every 4-6 hours as needed for pain: only if refractory to ibuprofen, fentanyl, tylenol. watch out for sedation, confusion. 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. senna 8.6 mg capsule sig: one (1) tablet po bid (2 times a day) as needed for constipation. 8. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical daily (daily): 12 hours on, 12 hours off. 9. bisacodyl 5 mg tablet, delayed release (e.c.) sig: [**1-20**] tablet, delayed release (e.c.)s po daily (daily) as needed for constipation. 10. ibuprofen 200 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. 11. aspirin 325 mg daily discharge disposition: extended care facility: [**hospital3 2558**] - [**location (un) **] discharge diagnosis: primary: altered mental status, afib with rvr, acute kidney injury, hypercalcemia, acute on chronic diastolic heart failure secondary: presumptive squamous cell lung cancer, pain, mild as discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. [**known lastname 14535**], it was a pleasure taking care of you at [**hospital1 18**]. you were admitted for confusion and falls. this may have been related to the increase in your fentanyl patch dose or your high calcium. this resolved with decrease of fentanyl dose back to your previous dose and improvement of your calcium with a drug called a bisphosphonate. you also developed atrial fibrillation. this improved with medications and resolved and did not occur again. we clarified your goals of care which include priorities of: 1) maintaining a clear mental status 2) controlling pain. the priority is on maintaining a clear mental status over controlling pain for now. your kidney function and blood pressures were initially low, but this improved with hydration. the following changes were made to your medications: stop doxazosin stop clonidine stop nifedipine stop labetalol stop hydrochlorothiazide stop enalapril decrease fentanyl to 25 mcg patch/hr q 72 hours start lidocaine patch for shoulder and hip pain start ibuprofen 200-400 mg q4-6h prn for pain start oxycodone for pain start bowel regimen with senna, colace, bisacodyl followup instructions: please have your rehab facility schedule an outpatient follow up appt with: name: [**last name (lf) **],[**first name3 (lf) **] l. location: [**hospital1 **] healthcare - [**location (un) **] address: [**state 4607**], [**location (un) **],[**numeric identifier 588**] phone: [**telephone/fax (1) 4606**] completed by:[**2177-6-10**]",1
31,"admission date: [**2144-3-21**] discharge date: [**2144-4-20**] date of birth: [**2070-6-18**] sex: f service: chief complaint: transfer from [**hospital3 **] with a left hip fracture. history of present illness: the patient is a 73 year-old female with end stage renal disease on hemodialysis since [**2141**], secondary to diabetes mellitus. she has atrial fibrillation and several other medical and surgical problems and is a resident of an [**hospital3 **] facility, who at baseline has a history of mechanical falls and is a fall risk. she most recently fell on [**2144-3-16**] (mechanical fall) and was admitted to [**hospital3 **] where she was diagnosed with a left intratrochanteric fracture of the femur. she was given morphine for pain and has had altered mental status since then. per her [**hospital3 **] discharge summary, the patient had a pharmacology stress test, which was normal as well as ruled out for myocardial infarction by serial enzymes. the patient was placed on a heparin drip for deep venous thrombosis prophylaxis and was transferred to the [**hospital1 69**] for further evaluation/surgery. past medical history: 1. end stage renal disease secondary to diabetes mellitus, on hemodialysis since [**2141**]. 2. diabetes mellitus type 2 - diabetic neuropathy, diabetic retinopathy. 3. hypertension. 4. question peripheral vascular disease. 5. gastroesophageal reflux disease. 6. atrial fibrillation (has a history of rapid atrial fibrillation). 7. congestive heart failure ? diastolic. ef of greater then 55% in [**4-28**]. 8. coronary artery disease. per omr in [**2136**] she had clean coronaries by cardiac catheterization. 9. glaucoma. 10. hypercholesterolemia. 11. depression. 12. vertebral compression fractures. 13. ligation of left av graft secondary to ulna steel phenomenon. 14. breast cancer (left dcis) status post lumpectomy. 15. osteoarthritis. 16. history of klebsiella bacteremia in [**4-28**]. 17. question restrictive lung disease. 18. left ulnar nerve palsy secondary to steel phenomenon from left forearm av graft. past surgical history: 1. total abdominal hysterectomy. 2. left third toe amputation, gangrene with focal chronic osteomyelitis. 3. left partial mastectomy for left dcis in 7/98. 4. [**3-/2141**] vitreous hemorrhage, retinal detachment of left eye status post partial vitrectomy. 5. [**6-/2141**] right brachial cephalic av fistula and right ij quinton catheter. 6. [**8-/2141**] carotid right ij. removal and insertion. 7. [**1-29**] right ij tesio hemodialysis catheter. 8. [**4-28**] removal/insertion of right ij tesio catheter secondary to klebsiella bacteremia. 9. [**5-29**] removal/insertion of right ij tesio secondary to malfunction. 10. [**11-29**] left forearm av graft with [**doctor last name 4726**]-tex. 11. [**12-29**] ligation of left av graft secondary to steel phenomenon. allergies: 1. codeine (percocet/darvocet) - the patient is very sensitive to any narcotics. she will have a decrease mental status for two to three days post administration of small doses of narcotics. 2. penicillin. 3. sulfa. 4. question verapamil (no documented reaction or history). medications on admission (per omr in [**10-29**]): 1. effexor xr 150 mg po q.h.s. 2. lactulose 30 cc po q.o.d. 3. lipitor 20 mg po q.h.s. 4. lopresor 25 mg po b.i.d./t.i.d. 5. nephrocaps one cap po q.d. 6. prevacid 15 mg po q.a.m. 7. renagel 800 mg po t.i.d. social history: the patient lives at an [**hospital3 **] facility. contacts: the patient's primary contact should be is [**name (ni) **] work number is 1-[**numeric identifier 16782**]. [**doctor first name 16783**] home number is [**telephone/fax (1) 16784**]. her cell phone number is [**telephone/fax (1) 16785**]. physical examination on admission: temperature 100.4. blood pressure 140/70. pulse 98. respiratory rate 20. o2 saturation 96% on room air. in general, she was awake, oriented only to person. her heent poor dentition. mucous membranes are moist. oropharynx is pink. cardiovascular irregularly irregular 1 to 2/6 systolic murmur. no elevated jvp. chest bilaterally clear to auscultation, bilateral basilar crackles. no wheezing. abdomen soft, nontender, nondistended, positive bowel sounds, normal bowel sounds times four quadrants. extremities bilateral lower extremities are warm, no edema. skin right neck with hemodialysis line intact, no erythema of skin. no tenderness. stage 1 sacral decubitus ulcers. laboratory data on admission: white blood cell count is 7.9, hemoglobin 10.1, hematocrit 33.7. (baseline 32 to 34% on [**12-29**]). mean corpuscular volume 103, rdw 15, platelets 187, pt 13.4, inr 1.2, sodium 141, potassium 4.5, chloride 107, bicarb 20, bun 26, creatinine 4.6 (baseline is 3.8 to 8.3 through [**2143**]), glucose 253, alt 11, ast 15, alkaline phosphatase 162 (baseline is 156 to 180 through [**2142**]-[**2143**]), total bilirubin is 0.6, albumin 3.4, calcium 9.1, phosphorus 3.6, magnesium 1.8. data: echocardiogram on [**4-28**] mild [**name prefix (prefixes) **] [**last name (prefixes) 13385**], mild left ventricular hypertrophy, ef greater then 55%. physiologic (normal) mitral regurgitation, trivial tricuspid regurgitation, left ventricular retinal wall motion is normal. holter ([**3-1**]) - atrial fibrillation with average ventricular response. no symptoms during monitoring. impression on admission: this patient is a 73 year-old female with end stage renal disease on hemodialysis and atrial fibrillation who suffered a mechanical fall and is now transferred to [**hospital1 69**] for a left intratrochanteric hip fracture. she had a low grade temperature currently question infectious etiology. blood cultures were drawn on admission. orthopedic surgery was consulted for evaluation and recommendations. for evaluation of her left hip ap pelvis and ap true lateral films of the left hip were done. preoperative cardiac assessment of this patient revealed a history with no coronary artery disease, but positive hypertension, positive hypercholesterolemia, but a clean catheterization in [**2136**]. cardiac risk gratification for noncardiac surgical procedures was intermediate to high with orthopedics surgery with a reported cardiac risk of generally less then 5%. the patient had a persantine (pharmacologic) stress test at [**hospital3 **], which was negative on [**2144-3-18**]. the official report from [**hospital3 16786**] was reviewed. the patient subsequently had a very extensive prolonged medical stay for approximately one month. the following is a date synopsis of the major events during her hospital admission. [**2144-3-22**]: the patient was admitted. patient with low grade fever 100.4, white blood cell count was normal at 7.9. [**2144-3-22**]: the patient was in the preop orthopedics area prior to surgery. became hypotensive with rapid atrial fibrillation, heart rates in the 140s to 150s. the patient was taken back to the floor, and intravenous diltiazem was pushed. blood cultures that were taken on admission subsequently grew out gram positive coxae. the patient was started on vancomycin empirically. [**2144-3-23**]: right ij perm-a-cath pulled by transplant surgery. [**2144-3-24**]: temporary line number one was placed in her right groin by renal. [**2144-3-26**]: question of endocarditis. pte is negative. [**2144-3-28**]: temporary groin line number one in the right femoral area was discontinued by renal. [**2144-3-31**]: question infectious fossae from the gram positive coxae bacteremia, which has subsequently grown out to be mrsa. white blood cell scan was obtained to evaluate for septa fossae given the fact that the patient had a right temporary groin line in, has an old left av [**doctor last name 4726**]-tex graft. the white blood cell scan was negative or any septic fossaei. it showed increased uptake in the bone marrow (consistent with infectious process), and increase uptake in the sacral area, consistent with her sacral decubitus ulcers. [**2144-3-30**]: nasogastric tube was placed. tube feeds and po medications administered this way. [**2144-3-31**]: temporary right groin line hemodialysis number two was placed. [**2144-4-2**]: transplant surgery is unable to place a left or right ij or right subclavian. procedure was aborted in the operating room. [**2144-4-2**]: left open reduction and internal fixation, dhs by orthopedics surgery procedure. no problems or complications. [**2144-4-4**]: left ij perm-a-cath placed by transplant surgery. postoperatively, the patient had increased white blood cells in urine, hypotensive. the patient was neo-synephrine. transferred to the micu. since her blood cultures from [**3-21**] through [**3-25**] were positive, since [**2144-3-25**] cultures have been negative. [**2144-4-5**]: urine cultures are growing out proteus. blood cultures are with gram negative bacteremia in the micu. the patient was started on levofloxacin. the patient was also weaned off neo-synephrine. [**2144-4-7**]: the patient is growing out gram positive coxae in her blood cultures. presumed to be enterococcus, started on linezolid given her recent hip surgery as well as port-a-cath. [**2144-4-8**]: the patient was transferred back to the floor hemodynamically stable. [**2144-4-9**]: infectious disease was reconsulted. [**2144-4-10**]: picc was placed on the right basilic vein. right groin line (was pulled). [**2144-4-11**]: left perm-a-cath is malfunctioning. there was no flow. hemodialysis was aborted. [**2144-4-13**]: interventional radiology replaced a perm-a-cath in the same site. [**2144-4-14**]: ir had to change the perm-a-cath again, ? puncture of the first perm-a-cath they placed when changing over a guidewire. [**2144-4-15**]: the patient developed a right common femoral vein, superficial femoral vein deep venous thrombosis. [**2144-4-17**]: increased alkaline phosphatase to the 190s. right upper quadrant ultrasound showed gallstones, in common bile duct 3 mm, no acute process. [**2144-4-18**] - [**2144-4-19**]: the patient's inr is therapeutic. heparin was discontinued. hospital course: 1. orthopedic: the patient has a left intratrochanteric hip fracture. it was repaired by orthopedic surgery with a left open reduction and internal fixation and dynamic hip screw on [**2144-4-2**]. the patient tolerated the procedure well. no problems. 2. cardiovascular: the patient has a history of atrial fibrillation, with a history of rapid ventricular response. various times throughout the admission she has required 10 to 20 mg if intravenous diltiazem to bring her rate down. she is currently stable on a po (via nasogastric tube) regimen of metoprolol 50 mg po t.i.d. 3. renal: the patient has end stage renal disease on hemodialysis. hemodialysis is typically done on tuesday, thursday, saturday. she has had numerous transplant catheter perm-a-cath issue as dated above with the time line synopsis. she currently has a left sided perm-a-cath, which is functioning well. 4. prophylaxis: the patient was placed on a ppi, and then switched to ppi intravenous when she was not taking po and then was changed to h2 blocker via her nasogastric tube. because she is a renal patient lovenox should not be used as the levels cannot be monitored. the patient was initiated on a heparin drip with various therapeutic levels, when she developed the right femoral vein/right common femoral vein/right superficial femoral vein deep venous thrombosis. her right thigh was greatly enlarged and tender to palpation. she was started on coumadin and was therapeutic on coumadin times two days before the heparin was discontinued. per orthopedic recommendations the patient is to remain anticoagulated for six weeks postoperatively. the patient's surgery was on [**2144-4-2**], and she should be anticoagulated for six weeks postoperatively. recommend reultrasound of her right thigh in six weeks to determine the presence/absence/resolution of deep venous thrombosis. given the fact that this patient is nonmobile, she is likely to need anticoagulation or prophylactic anticoagulation with subq heparin for the time that she is immobile/decreased mental status/not walking/nonmobile at all. of note, her right popliteal vein is patent. 5. allergies/adverse reactions: the patient is exquisitely sensitive to narcotics. 1 mg of morphine causes this patient to have decreased mental status for approximately one to two to three days. narcotics (darvocet/percocet/morphine) should be judiciously avoided in this patient. 6. pulmonary: throughout this patient's entire admission her oxygen saturation has remained 95 to 100% on room air. she shows no signs of aspiration pneumonia, though she is an aspiration risk. recommend keeping her bed at 30 degrees to 45 degrees and using all aspiration precautions. serial chest x-rays were obtained on this patient, which have been negative for any pneumonia. she does have coarse breath sounds anteriorly, which sounds like transmitted upper airway sounds. 7. left foot drop: the patient has a left foot drop, which is consistent with a peroneal nerve distribution. mri of the lumbosacral spine was obtained to evaluate for any anatomic abnormalities. the mri showed numerous compression fractures in l3-s1 region, but no distinct abnormalities that would cause a specific foot drop. her foot drop is likely secondary to compression from behind her knee, during orthopedic surgery or secondary to placement of her legs while she was [**date range **]. no nerve conduction studies were done. 8. decreased mental status: the patient has had a decreased mental status since admission on [**2144-3-21**]. she has had numerous cts, white blood cell scans of her head, which have all revealed no evidence of subdural hematomas, no intracranial or axial hemorrhage, no evidence of any infarcts. there are no mass lesions or any shift effect. her decreased mental status is likely secondary to her toxic/metabolic state. a lumbar puncture was considered, however, the patient's mental status has been improving over the week prior to discharge and she is now able to state her name and communicate somewhat though this does wax and wane. it is anticipated that her mental status should clear somewhat as her medical condition improves, however, and she has a depressed mental status times one month, question how much toxic metabolic recovery she will have. 9. mrsa/bacteremia: the patient completed vancomycin treatment times twelve days. in addition, after the patient was placed on linezolid this would also cover mrsa bacteremia as well. 10. proteus urinary tract infection, causing sepsis: the patient completed a two week cousre of levofloxacin. 11. vre bacteremia: the patient is to finish completing a two week cousre of linezolid. this cousre will end on [**2144-4-23**]. 12. anticoagulation: the patient is to continue anticoagulation for six weeks [**last name (lf) **], [**first name3 (lf) **] [**2144-4-2**] orthopedics surgery. recommend continuing ppi/h2 blocker. 13. right deep venous thrombosis, common femoral vein, superficial femoral vein, with a greatly enlarged right thigh: [**initials (namepattern4) **] [**last name (namepattern4) 260**] filter was considered for prophylaxis against pulmonary embolis. however, it is thought that the patient had her heparin turned on and off intermittently for different procedures and though her heparin levels were therapeutic, question of whether she had transient subtherapeutic levels that were not detectable by laboratory, which may have contributed to her tpt. it is recommended she discontinue all anticoagulation. 14. fen: the patient is being given tube feeds (nephro/renal diet) per nutrition recommendations. the patient has had an nasogastric tube in her nose since [**2144-3-30**]. if the patient's mental status does not improve within the next month, ? consideration of a peg. when the patient is more awake recommend a bedside speech and swallow evaluation for this patient. she is npo except for ice chips right now. she is an aspiration risk and her head of the bed should be elevated at 30 degrees to 45 degrees. she showed no signs of aspiration pneumonia at this time. 15. hypoglycemia: the patient is on regular insulin sliding scale. her finger sticks have been in the range from the 100s to 250. recommend continuing insulin sliding scale. if her blood glucose level is greater then 200 consistently, recommend starting low dose of nph. 16. elevated alkaline phosphatase: total bilirubin is normal. the patient has a history of increased alkaline phosphatase. a ggt level was obtained, which was 114. right upper quadrant ultrasound revealed gallstones, but no gallbladder wall thickening and a common bile duct of 3 mm. no cholecystitis. no abdominal pain, no right upper quadrant tenderness. abdominal examination has been benign. 17. code status: the patient is full code per her families wishes. discharge disposition: the patient is to be discharged to a rehabilitation facility. discharge medications: 1. atorvastatin 20 mg po q.h.s. 2. tylenol 325 to 650 mg po q 4 to 6 hours prn. 3. miconazole powder b.i.d. prn. 4. linezolid 600 mg po q 12 hours times three days through [**2144-4-22**]. 5. ranitidine 150 mg po q.d. 6. metoprolol 50 mg po t.i.d. 7. coumadin 2.5 mg po q.h.s. 8. regular insulin sliding scale. 9. epoetin 3000 units subq three times per week (monday, wednesday and friday). discharge instructions: 1. inr levels should be checked q day to monitor for variations. she is to be kept therapeutic with an inr level between 2 to 3. if her inr is stabilized, inr can be checked q week. she is to be anticoagulated for six weeks [**month/day/year **] orthopedic surgery. 2. the patient requires hemodialysis for her end stage renal disease. typically on tuesday, thursday, saturday. this is to be arranged by renal/hemodialysis team. 3. the patient has low grade fevers and it is recommended that she recieve blood cultures times two, urinalysis via straight catheter as well as urinary culture. 4. if mental status has not improved in the next several weeks recommended peg tube for administration of medications as well as tube feeds. discharge diagnoses: 1. mrsa bacteremia. 2. vre bacteremia. 3. proteus urinary tract infection leading to sepsis/proteus bacteremia. 4. left intratrochanteric hip fracture. 5. end stage renal disease on hemodialysis. 6. atrial fibrillation, with rvr. 7. altered mental status. 8. left foot drop. 9. vertebral compression fractures. 10. diabetes mellitus type 2. 11. hypertension. 12. gastroesophageal reflux disease. 13. question congestive heart failure, ef is approximately 80%. left ventricular systolic function was hyperdynamic. trivial mitral regurgitation, tricuspid regurgitation, left atrium mildly dilated. this is per an echocardiogram done on [**2144-3-26**]. 14. status post numerous perm-a-cath placements/removal. 15. right deep venous thrombosis. 16. elevated alkaline phosphatase of unknown significance. [**first name8 (namepattern2) **] [**last name (namepattern1) **], m.d. [**md number(1) 1331**] dictated by:[**last name (namepattern1) 16787**] medquist36 d: [**2144-4-20**] 10:00 t: [**2144-4-20**] 10:27 job#: [**job number 16788**]",1
32,"admission date: [**2192-3-21**] discharge date: [**2192-4-4**] date of birth: [**2136-12-24**] sex: f service: medicine allergies: vancomycin / iodine; iodine containing / tape / ibuprofen / levofloxacin / bactrim attending:[**doctor first name 2080**] chief complaint: dyspnea, cough major surgical or invasive procedure: tracheotomy change to cuffed 6 french cuff history of present illness: hpi: ms. [**known lastname **] is a 55 yof with type i diabetes, morbid obesity (wheelcheer bound), cad s/p cabg, diastolic chf, sarcoidosis, asthma complicated by airway obstruction with chronic uncuffed tracheostomy, and neurogenic bladder with chronic indwelling urinary catheter who presented from home after experiencing worsening dyspnea on [**2192-3-21**]. the pateint states while watching tv she became more short of breath than usual, took albuterol which, helped but not as much as should so she came in. she noted she had been having a productive cough with brown sputum but no fevers. . in the ed her vitals were 98.3 85 131/67 20 95 (on home 02 of 2.5l). her cxr showed mild pulmonary edema, stable severe cardiomegaly and a small left pleural effusion. her creatinine was 1.6 (up from baseline 1.1) so she was not given lasix. ekg showed some changes-diffuse st flattening, now more depressed inferior and laterally. the patient was given aspirin. bnp was 5861 and the pt was admitted to medicine for chf exacerbation. ros: (+) as per hpi. pt denied ha, cp, cough, change in diet prior to hospitalization ,medication noncompliance, fever, chills, nausea, vomiting, or change in mbs. she has urinary incontinence at baseline and has a chronic catheter. ros: (+) as per hpi. pt denied ha, cp, cough, change in diet prior to hospitalization ,medication noncompliance, fever, chills, nausea, vomiting, or change in mbs. she has urinary incontinence at baseline and has a chronic catheter. . past medical history: <br><b>past medical history: </b> morbid obesity asthma diastolic heart failure diabetes mellitus type 1 (since age 16): neuropathy, gastroparesis, nephropathy, & retinopathy sarcodosis ([**2175**]) tracheostomy - [**3-13**] upper airway obstruction, sarcoid. [**2191-5-19**] trach changed from #6 cuffed portex to a #6 uncuffed, nonfenestrated portex arthritis - wheel chair bound neurogenic bladder with chronic foley asthma hypertension pulmonary hypertension hyperlipidemia cad s/p cabg [**2179**] (svg to om1 and om2, and lima to lad) last c. cath [**2187-2-28**]: widely patent vein grafts to the om1 and om2, widely patent lima to lad (distal 40% anastomosis lesion). chronic low back pain-disc disease s/p cholecystectomy s/p appendectomy history of sternotomy, status post osteomyelitis in [**2179**]. leukocytoclastic vasculitis [**3-13**] vancomycin in [**2179**]. history of pneumothorax in [**2179**]. colon resection, status post perforation. j-tube placement in [**2173**]. social history: the patient formerly lived alone and has a female partner for 25 years that visits frequently and is her hcp. she had been living in rehab recently, but most recently discharged home w/o services. the patient is mobile with scooter or wheelchair and can walk short distances. remote smoking history <1 pack per day >30 years ago, denies etoh or drug use. family history: father: [**name (ni) **], diabetes & mi in 60s mother's side: family history of various cancers & heart disease physical exam: physical exam: vitals: t: 98.7 p: 72 bp: 140/62 r: 20 sao2: 100% on 10 l (fio2 40%) general: awake, alert, nad, eating dinner heent: nc/at, eomi without nystagmus, no scleral icterus noted, mmm, no lesions noted in op neck: no lymphadenopathy, no elevated jvd pulmonary: lungs cta bilaterally, poor air movement cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted. extremities: no c/c/e bilaterally, 2+ radial, dp pulses b/l. skin: no rashes or lesions noted. neurologic: -mental status: alert, oriented x 3. able to relate history without difficulty. -cranial nerves: ii-xii intact pertinent results: labs on admission: [**2192-3-21**] 02:41am blood wbc-9.1 rbc-4.15* hgb-12.4 hct-38.3 mcv-92 mch-29.9 mchc-32.4 rdw-14.3 plt ct-135* [**2192-3-21**] 02:41am blood neuts-92* bands-0 lymphs-6* monos-2 eos-0 baso-0 atyps-0 metas-0 myelos-0 [**2192-3-21**] 02:41am blood pt-12.2 ptt-23.8 inr(pt)-1.0 [**2192-3-21**] 02:41am blood glucose-359* urean-65* creat-1.6* na-127* k-8.3* cl-91* hco3-30 angap-14 [**2192-3-21**] 02:41am blood ck(cpk)-124 [**2192-3-21**] 02:41am blood ck-mb-3 probnp-5861* [**2192-3-21**] 02:41am blood ctropnt-<0.01 [**2192-3-21**] 11:07am blood ck-mb-notdone ctropnt-<0.01 [**2192-3-21**] 02:34pm blood ck-mb-notdone ctropnt-<0.01 [**2192-3-21**] 02:34pm blood calcium-9.0 phos-4.5 mg-2.3 abg prior to micu transfer [**2192-3-21**] 08:12am blood type-art po2-55* pco2-66* ph-7.30* caltco2-34* base xs-3 labs on discharge [**2192-4-4**] 06:02am blood wbc-8.5 rbc-3.94* hgb-11.4* hct-35.1* mcv-89 mch-29.0 mchc-32.6 rdw-13.7 plt ct-216 [**2192-4-1**] 05:38am blood neuts-79.7* lymphs-14.5* monos-4.0 eos-1.5 baso-0.3 [**2192-4-4**] 06:02am blood glucose-131* urean-34* creat-1.1 na-137 k-4.0 cl-93* hco3-36* angap-12 [**2192-4-4**] 06:02am blood alt-82* ast-31 alkphos-202* totbili-0.9 [**2192-4-4**] 06:02am blood calcium-8.8 phos-3.7 mg-1.5* [**2192-4-1**] 05:38am blood caltibc-299 ferritn-326* trf-230 [**2192-3-31**] 04:21am blood hbsag-negative hbsab-negative hbcab-negative hav ab-negative micro: [**2192-3-23**] 3:20 am urine source: catheter. urine culture (preliminary): klebsiella pneumoniae. 10,000-100,000 organisms/ml.. gram negative rod(s). ~[**2182**]/ml. sensitivities: mic expressed in mcg/ml _________________________________________________________ klebsiella pneumoniae | ampicillin/sulbactam-- 8 s cefazolin------------- =>64 r ceftazidime----------- =>64 r ceftriaxone----------- =>64 r ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- <=16 s piperacillin/tazo----- =>128 r tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s images: ekg [**2192-3-23**]: sinus tachycardia with increase in rate as compared with previous tracing of [**2192-3-21**]. atrial ectopy persists. there is baseline artifact. the st-t wave changes are less prominent but this may represent pseudonormalization. clinical correlation is suggested. . ekg [**2192-3-22**]: sinus rhythm. premature atrial contractions. borderline left axis deviation with possible left anterior fascicular block. diffuse st-t wave changes. cannot rule out myocardial ischemia. compared to the previous tracing of [**2191-7-22**] inferior and anterolateral st-t wave changes are more prominent. clinical correlation is suggested. . echo [**2192-3-21**]: the left atrium is mildly dilated. 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 low normal (lvef 50-55%). there is no ventricular septal defect. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. . [**2192-3-22**] cxr: findings: as compared to the previous radiograph, there is unchanged mild-to-moderate pulmonary edema. blunting of the left costophrenic sinus, so that a small left pleural effusion cannot be excluded. unchanged low lung volumes, unchanged moderate cardiomegaly. no focal parenchymal opacities suggesting pneumonia. . [**2192-3-23**] cxr: 1. moderate cardiomegaly with increased moderate pulmonary edema compared to [**2192-3-22**]. 2. retrocardiac opacity most likely represents left basilar atelectasis. however, the differential diagnoses include layering left-sided pleural effusion, increased pulmonary edema, aspiration or pneumonia in the correct clinical setting. . [**2192-3-24**] cxr: there is again a tracheostomy tube in place, in good position. there is overall interval decrease in left lung base opacity compared to the prior examination. the left costophrenic angle is not seen. right hemithorax is unremarkable. no evidence of pneumothorax. no new parenchymal opacity is visualized. remainder of the examination is unchanged. kidney ultrasound [**2192-3-30**]: findings: no hydronephrosis of the right kidney or left kidney. the bipolar diameter of the right kidney is 9.8 cm and left kidney 8.8 cm. a 0.3 cm x 0.2 cm x 0.3 cm non-obstructing calculus is identified at the mid to lower pole of the right kidney. no other calculi are seen in the right kidney. a tiny hyperechoic focus at the mid pole of the left kidney most likely represents crystals and a caliceal diverticulum. no other focal abnormalities are seen in the left kidney. the urinary bladder is empty with a foley catheter in situ. liver ultrasound [**2192-3-30**]: findings: overall, evaluation is very limited by difficult son[**name (ni) 493**] penetration. no definite focal hepatic lesion is seen. the patient is status post cholecystectomy. dilation of the extrahepatic common duct to 1.2 cm is noted in the setting of mild left intra-hepatic biliary ductal dilatation, findings which are unchanged since a cta chest from 11/[**2189**]. the main portal vein demonstrates normal hepatopetal flow. no free fluid is seen in the right upper quadrant. impression: unchanged biliary ductal dilatation may be related to prior cholecystectomy, however the etiology is not completely certain. mrcp may be utilized for further evaluation, if clinically indicated. chest x ray [**2192-4-3**]: the patient has chronic low lung volumes which limit intrathoracic evaluation. the left pleural scarring/pleural effusion is unchanged . cardiac silhouette is moderately enlarged, also unchanged. tracheostomy tube is grossly normal. right picc terminates with its tip in the mid to distal svc. impression: no pulmonary edema or infectious process. brief hospital course: # dyspnea/respiratory distress: when pt arrived on the floor she was tachypnic and somnolent. she was sating 88-90% on 100% trach mask. normally she is on 2.5 liters trach mask at home. there was concern for chf exacerbation so lasix was given and pt had thick yellow urine. abg was 7.30/66/55. resp therapy was called to beside. pt has a size 6 cuffless trach. suctioning removed thick yellow secretions and sats improved to 97% on 50% trach mask. there was also some concern of twave changes on her ekg. she was transferred to the micu [**2192-3-24**] for respiratory distress. in the unit the patient had her trach changed to a cuffed trach in case she needed to be vented. however, she did not require this. she received nebs, suctioning, and iv lasix (80 mg with good result). cultures were obtained and the patient was empirically treated for pneumonia with cefepime and flagyl. the patient remained afebrile and her flagyl was stopped. the cefepime was kept as she had evidence of uti on ua. at time of transfer out from the icu to the medicine floor the patient had been diuresed 12 l over the length of stay. the patient continued to be diuresed on the medicine floor. however, she lost her iv access and received 80 mg lasix po bid instead of by iv. she continued to receive her albuterol, ipratropium, acetyl cysteine nebs. her o2 sats improved and she was able to tolerate fio2 of 35% which roughly corresponded to her 2.5 l o2 at home. she remained afebrile and her shortness of breath returned to baseline. the source of her exacerbation is unclear as she states she was compliant with medications and diet. she should continue her salt restricted diet, diuretics, and daily weight monitoring. #) assymptomatic bacteriuria: from chronic foley catheter (which was placed for neurogenic bladder). the patient was found to have a dirty ua and was initially started on cefepime in the icu. urine cultures grew klebsiella senisitive to cipro but the patient was allergic to floroquinolones so she was started on bactrim. however, this caused acute interstitial nephritis so it was stopped on day 5. her foley was changed and a repeat urinalysis and culture showed 6 wbcs, and 10,000 to 100,000 bacteria that eventually grew e coli (esbl). she was not started on antibiotics given that she was assymptomatic, has a chronic indwelling catheter and is likely colonized, there were less than 100,000 bacteria in the sample, and she has had multiple adverse reactions to antibiotics including her recent ain. she should get a repeat ua and culture when she goes to her follow up appointment with her pcp. [**name10 (nameis) **] patient was counseled to call her doctor or return to the ed if she felt like she was developing a uti. #) acute renal failure/acute interstitial nephritis: the pateint presented to the hospital with cr 1.6 up from 1.1. her creatinine improved to 0.8 with diuresis supporting poor forward flow as the cause of her arf. she developed acute renal failure again after starting the bactrim for her uti. her creatinine bumped up to 2.1 on day # 5 of antibiotics. renal was consulted and recommended stopping bactrim. after this was stopped her creatinine slowly improved. it was 1.1 the day of discharge. she should list bactrim as an allergy due to ain and not take this in the future. #) dyspepsia/nausea/transaminitis/hepatitis: on hospital day 8 the patient developed nausea that was first thought to be due to worsening gastroparesis as it was noticed she was not receiving her home reglan. this medication was restarted but the patient continued to have nausea without abdominal pain or diarrhea. her lfts were noted to be elevated with a cholestatic picture. a liver ultrasound was performed which showed unchanged biliary ductal dilatation. hepatology was consulted and they recommended a full work up given she has had elevated enzymes in the past but never had a work up to identify the source. initial hepatology labs were unrevealing including hepatitis serologies, igg, ttg, and fe levels (although she had an elevated ferretin). autoimmune antibodies, ceruloplasmin, and alpha 1 antitrypsin were pending at the time of discharge. hepatology also considered an mrcp and liver biopsy but these were not performed because her labs trended back down. it was thought that they may have transiently been elevated because of her chf exacerbation. nevertheless, she was set up with an appointment with the liver doctors to follow up on the rest of her labs and discuss the utility of a liver biopsy in the future as she may still have an underlying liver problem contributing to her acute elevation in enzymes given her history of elevated enzymes in the past. #) depression: the patient was continued on her home regimen of citalopram #) diabetes, type 2 uncontrolled: the patient was continued on glargine 54 u q hs with humalog sliding scale. her blood glucose was noted to be elevated despite her not taking in much po due to nausea. [**last name (un) **] was consulted and they recommended increasing her sliding scale. blood cultures were obtained to rule out infection but were negative. #) cad, native: the patient was continued on her metoprolol, aspirin, simvastatin, and valsartan #) dchf: echo performed showed ef 50-55%. bnp was elevated. the patient was aggresively diuresed. she was maintained on her valsartan and metoprolol. she was euvolemic at the time of discharge. #) pain control: the patient was continued on her home regimen of vicodin and gabapentin #) dispo: the patient lives at home and has vna once a month (per pt). although the patient enjoys her indiependence, it was thought that she would benefit from more assistance with monitoring, medication compliance, foley, and trach care. she was discharged with home services with vna who may determine if she required more care. . #) fen: the patient was placed on a p.o. diabetic, cardiac healthy diet . #) code status: full medications on admission: acetylcysteine 1 nebulizer treatment twice a day albuterol sulfate - 2.5 mg/3 ml (0.083 %) 1-2 puffs po twice a day benztropine mesylate - 1mg tablet three times a day butalbital-acetaminophen-caff [fioricet] - 50 mg-325 mg-40 mg tablet - 1 tablet(s) by mouth q4hr citalopram - 40 mg tablet once a day clopidogrel [plavix] 75 mg tablet once a day fluticasone-salmeterol [advair diskus] - 250 mcg-50 mcg/dose disk with device - 1 puff po twice a day furosemide - 60 mg tablet once a day gabapentin [neurontin] - 300 mg capsule po three times a day insulin glargine [lantus] 54u at bedtime insulin lispro [humalog] dosage uncertain ipratropium bromide - 0.2 mg/ml (0.02 %) 2 puffs po q6hr lorazepam - 2 mg tablet -po at bedtime as needed for insomnia may take additional one tab qam for anxiety metoclopramide - 60 mg tablet qd as directed--2 pills-1 pill-2 pills and 1 pill metoprolol tartrate - 50 mg tablet [**hospital1 **] normal saline - - to clean tracheotomy [**hospital1 **] and prn omeprazole - 20 mg capsule, delayed release(e.c.) - [**hospital1 **] ondansetron - 8 mg tablet, rapid dissolve [**hospital1 **] prn for nausea pnv w/o calcium-iron fum-fa [m-vit] 27 mg-1 mg tabletbid simvastatin - 20 mg tablet po qday valsartan [diovan] - 40 mg tablet po qday vicodin - 5-500mg tablet - 1-2 tabs po tid, prn for back and knee pains aspirin - 325 mg tablet po qday calcium carbonate [tums ultra] - 1,000 mg tablet, docusate calcium - 100mg capsule - po bid discharge medications: 1. acetylcysteine 20 % (200 mg/ml) solution [**hospital1 **]: one (1) ml miscellaneous [**hospital1 **] (2 times a day). 2. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization [**hospital1 **]: 1-2 puffs inhalation twice a day. 3. benztropine 1 mg tablet [**hospital1 **]: one (1) tablet po three times a day. 4. fioricet 50-325-40 mg tablet [**hospital1 **]: one (1) tablet po every four (4) hours. 5. citalopram 20 mg tablet [**hospital1 **]: two (2) tablet po daily (daily). 6. clopidogrel 75 mg tablet [**hospital1 **]: one (1) tablet po daily (daily). 7. advair diskus 250-50 mcg/dose disk with device [**hospital1 **]: one (1) puff inhalation twice a day. 8. furosemide 20 mg tablet [**hospital1 **]: three (3) tablet po once a day. 9. neurontin 300 mg capsule [**hospital1 **]: one (1) capsule po three times a day. 10. insulin glargine 100 unit/ml solution [**hospital1 **]: fifty four (54) units subcutaneous at bedtime. 11. insulin lispro subcutaneous 12. ipratropium bromide 0.02 % solution [**hospital1 **]: two (2) puffs inhalation qid (4 times a day). 13. lorazepam 1 mg tablet [**hospital1 **]: two (2) tablet po at bedtime as needed for insomnia: may take additional tab qam for anxiety. 14. metoclopramide oral 15. metoprolol tartrate 50 mg tablet [**hospital1 **]: one (1) tablet po bid (2 times a day). 16. normal saline flush 0.9 % syringe [**hospital1 **]: one (1) trach flush injection twice a day: prn to clean tracheotomy. 17. omeprazole 20 mg capsule, delayed release(e.c.) [**hospital1 **]: one (1) capsule, delayed release(e.c.) po twice a day. 18. ondansetron 8 mg tablet, rapid dissolve [**hospital1 **]: one (1) tablet, rapid dissolve po twice a day as needed for nausea. 19. pnv w/o calcium-iron fum-fa 27-1 mg tablet [**hospital1 **]: one (1) tablet po twice a day. 20. simvastatin 10 mg tablet [**hospital1 **]: two (2) tablet po daily (daily). 21. valsartan 40 mg tablet [**hospital1 **]: one (1) tablet po daily (daily). 22. hydrocodone-acetaminophen 5-500 mg tablet [**hospital1 **]: 1-2 tablets po q8h (every 8 hours) as needed for pain: prn for back and knee pain. 23. aspirin 325 mg tablet [**hospital1 **]: one (1) tablet po daily (daily). 24. docusate sodium 50 mg/5 ml liquid [**hospital1 **]: one (1) po bid (2 times a day). 25. calcium carbonate 1,000 mg tablet, chewable [**hospital1 **]: one (1) tablet, chewable po once a day. 26. psyllium packet [**hospital1 **]: one (1) packet po tid (3 times a day). 27. sulfamethoxazole-trimethoprim 800-160 mg tablet [**hospital1 **]: one (1) tablet po bid (2 times a day) for 11 days: last day = [**2192-4-4**]. disp:*22 tablet(s)* refills:*0* discharge disposition: home with service facility: [**location (un) 86**] vna discharge diagnosis: primary diagnosis: diastolic chf exacerbation klebsiella urinary tract infection acute renal failure secondary diagnosis: diabetes coronary artery disease pulmonary hypertension depression 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 came to the hospital because you were having trouble breathing. you were admitted but then had worsening shortness of breath so you were transferred to the intensive care unit. it was thought that you had an exacerbation of your chf which was the cause for the shortness of breath. you were given lasix and your breathing improved. you were also found to have a urinary tract infection and so you were started on bactrim antibiotics. unfortunately, this medication caused you to have damage to your kidney so it was stopped. you should not take this antibiotic in the future. repeat urine cultures showed a small amount of bacteria but we thought that it was contamination and with the risks of antibiotic use on your kidneys we decided not to treat this. if you develop any symptoms of a urinary tract infection you should call dr. [**name (ni) 16684**] office right away. you also were noted to have nausea and abnormalities in your liver [**name (ni) **] tests. it was thought that your nausea was from your gastroparesis. you were evaluated by the liver specialists who thought the abnormal liver labs were caused by your chf. they improved over time. because this is not the first time your liver labs have been abnormal the liver specialists think you should follow up with them as an outpatient to see if you need further testing. no changes have been made to your medications. however, you should note that bactrim should be added to your list of medications that cause allergy and you should not take this drug in the future. please go to your follow up appointments (see below). please continue to take all of your medications as prescribed and adhere to a low salt diet. you should weigh yourself every morning, and call your primary care doctor if your weight goes up more than 3 lbs. it was a pleasure taking part in your care. followup instructions: please have your visiting nurse draw your blood next monday or tuesday to check your liver enzymes and white blood cell count. please have these results sent to your primary care doctor, dr. [**last name (stitle) **]. her phone number is [**telephone/fax (1) 250**]. please go to your follow up appointment at your primary care clinic for post-hospitalization check up. we have made this appointment for you. you will be seeing a nurse [**last name (titles) 16685**], [**last name (lf) **],[**first name3 (lf) **] g., on [**4-23**] at noon. you also have an appointment with dr. [**last name (stitle) **] on [**6-4**] at 4:10 pm. the phone number for dr. [**last name (stitle) **] is [**telephone/fax (1) 250**] if you need to change these appointments. it is very important that you go to your follow up appointment on [**4-23**] because we want to check your urine to make sure that you do not develop another urinary tract infection. please call the office if you develop symptoms before this appointment. you also have a follow up appointment with the liver doctors. you will be seeing dr. [**first name (stitle) **]. at 3:40 pm on [**4-12**], located in the [**hospital unit name **] on the [**location (un) **], suite e. this has been scheduled as an 'urgent' visit and they are squeezing you in so you can be seen at this time. the phone number is ([**telephone/fax (1) 16686**] if you need to reschedule this appointment or call for directions.",1
33,"admission date: [**2111-1-23**] discharge date: [**2111-1-29**] service: medicine allergies: calcium channel blocking agents-benzothiazepines / ace inhibitors attending:[**first name3 (lf) 689**] chief complaint: n/v, abdominal pain major surgical or invasive procedure: none history of present illness: [**age over 90 **] y.o. female, resident at [**hospital3 2558**] with pmhx significant for multiple abdominal surgeries, including billroth 2 revised with conversion to roux-en-y gastrojejunostomy for pud and subtotal colectomy with ostomy for perforated bowel as well as cad s/p cabg in '[**98**] with patent grafts in '[**06**], atrial fibrillation, htn, hypothyroidism who presents with a chief complaint of rlq abdominal pain since last night. patient has chronic abdominal pain, usually occuring after meals, thought to be an anginal equivalent - often responding to sl nitro. she is reported to have suddenly grabbed the rlq of her abdomen lastnight complaining of pain. she later had an episode of ""coffee-ground"" emesis that was reportedly gastrocult negative. her ostomy output has not been melanic or with gross blood. she denies chest pain, shortness of breath, increased ostomy output, dysuria or hematuria. she was brought in to the [**hospital1 18**] er for further evaluation. . in the ed, vitals were t - 99.6, hr - 90, bp - 138/82, rr - 24, o2 - 94% (unclear if on room air). she later spiked to 103.6 and was increased to 4 liters o2 with 96% saturation. blood cultures and ua/ucx were drawn with ua strongly positive for uti. cxr also showed perihilar opacities concerning for pna and patient was empirically started on levofloxacin and flagyl. the abdominal pain was evaluated with a ct abdomen, which was initially concerning for an obstruction as minimal contrast was seen at the patient's colostomy. a subsequent kub then showed sufficient contrast through to the colostomy site, which along with an unremarkable surgical evaluation was ressuring for the absence of a bowel obstruction. ekg showed new std in the lateral leads and patient was given asa. her blood pressure was tenuous so she was not given a beta-blocker. ces were sent off and the patient was admitted to medicine for further work-up. ros: only remarkable for that mentioned above. per report from [**hospital3 2558**] nurse, patient received her influenza vaccine on [**2110-11-6**] and her pneumovax on [**2108-11-1**]. . on admission to the icu after being in the ed for 22 hours, she was feeling well with no real complaints. she did note that her abdomen was mildly tender diffusely with palpation, but denied dizziness, cp, sob, nausea, vomiting. her initial vs on admission to the icu were, t 97, bp 142/52, r 18, o2 95% 4 l nc, hr 72. past medical history: 1. pud s/p billroth 2, about 50y ago, recently s/p revision and conversion to roux-en-y gastrojejunostomy with placement of jejunal feeding tube [**1-3**] due to bleeding marginal ulcer at anastomotic site 2. cad s/p cabg [**2098**] svg -> rca, svg -> lad, svg -> lcx, cath [**8-3**] confirmed patent grafts 3. perforated bowel secondary to fecal impaction s/p subtotal colectomy c ostomy [**2099**] 4. paroxysmal atrial fibrillation 5. hypertension 6. chf, last echo [**2108-1-27**] ef 30-40% 7. b12 deficiency 8. hypothyroidism 9. breast cancer s/p lumpectomy and xrt [**2101**] 10. macular degeneration 11. chronic renal insufficiency 12. right corona radiata stroke [**1-3**] 13. chronic abdominal pain social history: smokes a few cigarettes a day, occasional alcohol consumption, and denies illicit drugs. patient states that she used to smoke more. she was born in [**location (un) 86**] and has been a life-[**first name8 (namepattern2) **] [**location (un) 86**] resdident. she lives currently at [**hospital3 **] in [**location (un) 583**], ma. prior to that she lived alone and was independent. her husband passed away several years ago. she has 3 daughters who are all in her 60s. she has 3 grandsons, 1 great-grandson, and 1 great-granddaughter. [**name (ni) **] health care proxy is her daughter, [**name (ni) **] [**name (ni) 6955**] ([**telephone/fax (1) 18144**]). family history: both parents passed away, unknown cause per patient. denies family h/p cad, mi, cancer, cva, dm. physical exam: pe on micu admission: vitals: t 97, bp 142/52, r 18, o2 sat 95% 4l nc, hr 72 general: awake, alert, oriented x 3, pleasant, nad heent: nc/at; perrla; op clear with dry mucous membranes neck: supple, no lad, no jvd chest/cv: s1, s2 nl, no m/r/g appreciated lungs: ctab abd: soft, diffusely tender to palpation, + bs, ostomy in place, well-appearing, draining green stool that is guaiac positive ext: no c/c/e neuro: grossly intact skin: no lesions pertinent results: ekg: sinus, nl intervals, prolonged pr, narrow qrs, twi in v4-v6 (new compared to prior) . labs: (see below) . imaging: cxr ([**1-22**]): patient is status post median sternotomy and cabg. there is stable borderline cardiomegaly. the thoracic aorta is calcified and tortuous. there are new perihilar patchy airspace opacities concerning for aspiration or pneumonia. no pneumothorax or sizable pleural effusion. osseous structures are grossly unremarkable. impression: perihilar airspace disease with air bronchograms concerning for aspiration or pneumonia. . ct abdomen/pelvis ([**1-23**]): 1. perihilar and left basilar airspace consolidation concerning for aspiration or pneumonia. 2. mild gaseous distention of the afferent limb of the roux-en-y with enteric contrast seen within the efferent limb extending to the left pelvis with more distal collapsed loops of distal ileum extending to the right ileostomy. some enteric contrast does appear to extend to the ostomy site. it is unclear if the findings are secondary to the relatively short oral prep time or represent a very early small-bowel obstruction. continued surveillance is recommended. 3. stable cystic lesion in the head of the pancreas. 4. unchanged severe compression deformity of the l2 vertebral body. 5. dense calcification throughout the intra-abdominal arterial vasculature. . kub ([**1-23**]): a nonobstructed bowel gas pattern is evident with oral contrast seen projecting over the right lower lobe ostomy. there is a dense right renal shadow and contrast seen within both ureters from a recent ct scan. there is mild gaseous distention of the stomach. the lungs demonstrate perihilar airspace opacities concerning for pneumonia or aspiration. the aorta is calcified and ectatic. again noted is a compression fracture of l2 with severe dextroscoliosis of the lumbar spine. impression: satisfactory bowel gas pattern with progression of enteric contrast through the right lower abdominal ostomy. brief hospital course: a/p: [**age over 90 **] y.o. female with pmhx of multiple abdominal surgeries, cad s/p cabg, a. fib, hypothyroidism who presents with acute on chronic abdominal pain, found to have uti and overall septic picture. . # sepsis from uti: pt initially with tacchycardia and hypotension which resolved with fluids, and + ua. patient did have slight lactate elevation to 3.0, which resolved, and remained afebrile throughout stay. urine cx showed +pansensitive e.coli. pt intially started on vancomycin and zosyn empirically, narrowed to ceftriaxone, and then cipro for 14 day total course. foley was removed before discharge. . # abdominal pain: pt with chronic abdominal pain which worsened the morning of [**1-24**] in the setting of suspected sepsis from uti. pain greatest in luq pain, but abdomen was soft and mildly tender. lactate initially elevated, but resolved. upright kub showed no free air or obstruction. pt was transitioned to a ppi [**hospital1 **] and given tylenol q6hr for pain. c diff was negative x2, and pt had normal ostomy output. abdomininal pain improved on hd 3 when transfered to floor, and pt quickly advanced to full diet. did have reoccurance of general abdominal pain, but reports similar to previous ab pain. treated with tylenol # anemia: pt had anemia and recieved several blood transfusions. subsequent hcts have been stable . # atrial fibrillation: on coumadin as an outpatient with subtherapeutic inr intially. patient's chads2 score is 2 (htn, age; patient is reported to have had a cva, but previous head imaging is unremarkable), which puts her at moderate risk of embolic event for which she is on coumadin. initially held given coagulopathy and concern for gib. coumadin was restarted at 1 mg of [**1-24**] with a theraputic inr. concern for interaction with ciprofloxacin, so ctm inr. pt became tacchycardic to the 130's and betablockers were titrated to a hr of approximately 80. will d/c pt on elevated level of bb; metoprolol xl at 175 [**hospital1 **]. . # tacchypnea: pt with tachypnea and bilateral basilar crackles on exam. perihilar opacities on cxr, but not overtly suggestive of pna, but with vascular congestion. pt denies cough or sputum production and remained afebrile. pt recieved gentle diuresis with lasix - approx 1 l, with resolution of tacchypnea and subsequently maintained adequate o2 saturations on room air. . # cad: s/p cabg in [**2098**] with functional grafts demonstrated on cath in [**2106**]. currently denies cp, but ekg does show new twi in lateral leads. patient is on bb, asa, statin as an outpatient. transiently held beta-blockade to to hypotension, but then restarted; patient continued on asa and statin. ruled out for mi with 2 sets of ces 12 hrs apart. last echo was [**10-6**] and showed ef of 50-55%. continued home statin, asprin and betablocker . #. htn; initially held antihypertensives in setting of hypotension, but then returned the bb in form of metoprolol. metoprolol increased to titrate hr, with no adverse affect on bp. will hold amlodipine as pt has well controled bp and hr on metoprolol . # arf: creatinine increased to 1.6, from 1.1, likely prerenal in the setting of vomiting and insensible losses while febrile. ct abdomen did not demonstrate kidney stones or signs of obstruction. urine lytes c/w prerenal process as una is < 10. resolved with ifv . # hypothyroidism; continue home levothyroxine . # transaminitis/elevated pancreatic enzymes: resolved in micu with hydration . # fen; continued regular diet . # [**month/year (2) 5**]; continued home coumadin at a lower dose due to concerns of interaction with cipro. pt was placed on a ppi . # code status: dnr/dni per conversation with patient and patient's daughter. also documented on previous hospitalizations. [**name (ni) **] hcp and daughter is [**name (ni) **] [**name (ni) 6955**], np - ([**telephone/fax (1) 18146**] (c), ([**telephone/fax (1) 18147**] (h) medications on admission: medications: calcitonin salmon 200 units daily acetaminophen 325 mg po q6h levothyroxine sodium 80 mcg po daily aluminum-magnesium hydrox.-simethicone 30 ml po tid loperamide 2 mg po qid:prn amlodipine 5 mg po hs mirtazapine 45 mg po hs artificial tears 1-2 drop both eyes tid nitroglycerin sl 0.4 mg sl after meals and prn aspirin 81 mg po daily pantoprazole 40 mg po q24h atenolol 100 mg po daily --> metoprolol inpatient atorvastatin 10 mg po hs warfarin 2 mg po daily at 5pm . allergies/adverse reactions: pt. denies allergies, but per omr ccb ([**last name (un) 5487**]) ace-inhibitors (unknown) discharge medications: 1. calcitonin (salmon) 200 unit/actuation aerosol, spray sig: one (1) nasal daily (daily). 2. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours). 3. levothyroxine 88 mcg tablet sig: one (1) tablet po daily (daily). 4. aluminum-magnesium hydroxide 225-200 mg/5 ml suspension sig: 15-30 mls po tid (3 times a day). 5. loperamide 2 mg capsule sig: one (1) capsule po qid; prn as needed. 6. mirtazapine 15 mg tablet sig: three (3) tablet po hs (at bedtime). 7. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: [**12-31**] drops ophthalmic tid (3 times a day). 8. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) sublingual qac and prn. 9. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 11. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 12. warfarin 1 mg tablet sig: one (1) tablet po daily (daily). 13. ciprofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 10 days. 14. metoprolol succinate 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po twice a day. 15. metoprolol succinate 25 mg tablet sustained release 24 hr sig: three (3) tablet sustained release 24 hr po twice a day. tablet sustained release 24 hr(s) discharge disposition: extended care facility: [**hospital3 2558**] - [**location (un) **] discharge diagnosis: urinary tract infection discharge condition: good discharge instructions: you were hospitalized with a urinary tract infection. which has been treated with antibiotics (ciprofloxacin) treatment: * be sure to take the antibiotics exactly as prescribed and complete the entire course, even if you are feeling better. if you stop early, the infection could come back. * we changed your blood pressure medications by increasing your betablocker and stopping your amlodipine * we also decreased your warfarin because it can interact with the antibiotic you are recieving. please continue to follow your inr and adjust the coumadin appropriately. * otherwise, you should return to your regular home medications warning signs: call your doctor or return to the emergency department right away if any of the following problems develop: * you have shaking chills or fevers greater than 102 degrees(f) or lasting more than 24 hours. * you aren't getting better within 48 hours, or you are getting worse. * new or worsening pain in your abdomen (belly) or your back. * you are vomiting, especially if you are vomiting your medications. * your symptoms come back after you complete treatment. * your abdominal pain is worsening your you have any other concerns followup instructions: follow up with your primary care physician in the next two weeks. please call [**telephone/fax (1) 18145**] to make an appointment",0
34,"admission date: [**2149-11-29**] discharge date: [**2149-12-4**] date of birth: [**2072-3-16**] sex: f service: medicine allergies: ace inhibitors attending:[**last name (un) 11974**] chief complaint: palpitations and nsvt major surgical or invasive procedure: ep study history of present illness: the patient is a 77-year-old female with a past history of htn, hl, cad s/p mi x 3 and cabg x 2, ischemic cardiomyopathy (ef 30 %), h/o nsvt s/p icd (replaced 2 years ago), presenting from [**hospital3 **] with nsvt. . of note, patient was admitted to [**hospital1 18**] in [**month (only) 956**] after icd firing in the setting of vt from a coughing attack. she had been started on amiodarone on discharge, however, this was discontinued in [**month (only) 547**] secondary to tingling/twitching in her ears and a swollen throat. she was last seen in the device clinic in [**month (only) 205**], with no notable events on review. . she presented to [**hospital3 **] with the initial complaint of an episode of palpitations that she says began on wednesday night. she has been feeling this palpitations for a long time (many months) but they had always gone away after a few minutes. this episode, however, lasted for at least an hour and this is what brought her to the osh. she denies overt shortness of breath, abd pain, or nausea. she denies any chest pain but does endorse some dizziness. . on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. she denies recent fevers, chills or rigors. she denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. past medical history: hypertension hyperlipidemia cad s/p 3 mis cardiomyopathy, ef 25% nsvt with easily inducible sustained vt on ep study in [**3-/2136**] -cabg: x2 [**2126**], [**2132**], both done at nedh -percutaneous coronary interventions: -pacing/icd: [**company 1543**] micro [**female first name (un) 19992**] 2 icd placed on [**2136-3-29**]. exchanged for [**company 1543**] icd, entrust d154vrc ?in [**2143**] (last interrogation per [**hospital1 18**] webomr notes [**2145-9-7**]). 3. other past medical history: depression s/p ect s/p cholecystectomy s/p hysterectomy s/p thyroid surgery for a benign mass s/p cataract surgery social history: married. lives at home with her husband and her brother. -tobacco history: remote smoking history from age 20 to 30 -etoh: occasional social drinking -illicit drugs: none family history: mother died of mi at age 38, brother at age 37. other brother mi at age 60. father lived to age [**age over 90 **] and was healthy. no family history of arrhythmia, cardiomyopathies. physical exam: admission physical exam general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no jvd appreciated. cardiac: rate very irregular, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities but central scar noted, well-healed, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ radial 2+ dp 2+ pt 2+ left: carotid 2+ radial 2+ dp 2+ pt 2+ . discharge physical exam vitals - tm/tc: afeb/97.3 hr: 57-66 bp: 95/50 (90-114/50-67) rr: 16 02 sat: 98% ra in/out: last 24h: 1740/2050 last 8h: 0/675 general: nad. oriented x3. mood, affect appropriate. very pleasant heent: ncat. sclera anicteric. perrl, eomi. mmm. neck: supple with no jvd appreciated. cardiac: regular rate and rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities but central scar noted, well-healed, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ radial 2+ dp 2+ left: carotid 2+ radial 2+ dp 2+ pertinent results: admission labs [**2149-11-30**] 08:45am blood wbc-4.9 rbc-4.89 hgb-15.1 hct-44.4 mcv-91 mch-30.9 mchc-34.0 rdw-13.4 plt ct-208 [**2149-11-30**] 08:45am blood pt-13.5* ptt-30.4 inr(pt)-1.2* [**2149-11-30**] 08:45am blood glucose-109* urean-7 creat-0.6 na-141 k-3.9 cl-104 hco3-28 angap-13 [**2149-11-30**] 08:45am blood calcium-9.0 phos-3.5 mg-1.9 . discharge labs [**2149-12-4**] 07:10am blood wbc-4.4 rbc-3.76* hgb-11.9* hct-35.4* mcv-94 mch-31.6 mchc-33.5 rdw-13.4 plt ct-184 [**2149-12-3**] 07:55am blood pt-12.5 ptt-27.1 inr(pt)-1.1 [**2149-12-4**] 07:10am blood glucose-88 urean-4* creat-0.7 na-140 k-3.8 cl-101 hco3-30 angap-13 [**2149-12-4**] 07:10am blood calcium-9.2 phos-3.3 mg-2.0 . imaging [**2149-12-1**] [**month/day/year **]: the left atrium is elongated. the estimated right atrial pressure is 0-5 mmhg. there is mild symmetric left ventricular hypertrophy. there is severe regional left ventricular systolic dysfunction with thinning/akinesis of the inferolateral wall, mild dyskinesis of the inferior wall and apex. the remaining segments are mildly hypokinetic. overall left ventricular systolic function is severely depressed (lvef= 25 %). no masses or thrombi are seen in the left ventricle. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. the mitral valve leaflets are elongated. trivial mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: mild symmetric left ventricular hypertrophy with normal cavity size with extensive regional systolic dysfunction c/w multivessel cad or other diffuse process. compared with the prior study (images reviewed) of [**2149-3-27**], the findings are similar. . [**2149-12-4**] stress test: interpretation: this 77 yo woman s/p mi x3, cabg in [**2126**] and [**2132**], nonsustained mmvt and s/p icd was referred to the lab for arrhythmia evaluation. the patient completed 9 minutes of [**initials (namepattern4) **] [**last name (namepattern4) 4001**] protocol representing an average exercise tolerance for her age; ~ 4.8 mets. the exercise test was stopped at the patient's demand secondary to fatigue. no chest, back, neck or arm discomforts were reported by the patient during the procedure. the subtle st segment changes noted anteriorly are uninterpretable for ischemia in the presence of the rbbb. no significant st segment changes were noted inferiorly or in the lateral precordial leads. the rhythm was sinus with rare isolated apbs. in additional, rare isolated vpbs and one ventricular couplet was noted during the procedure. in the presence of beta blocker therapy, the heart rate response to exercise was limited. a flat blood pressure response was noted with exercise; resting standing 94/46 mmhg, peak exercise 104/46 mmhg. max rpp 8112, % max hrt rate achieved: 55 impression: average exercise tolerance, however decreased in exercise time/exercise tolerance from previous ett in [**2149-3-18**]. no anginal symptoms or objective ecg evidence of myocardial ischemia. no exercise-induced vt. blunted heart rate and blood pressure response to exercise. brief hospital course: 77-year-old female with a past history of htn, hl, cad s/p mi x 2 and cabg x 2, ischemic cardiomyopathy (ef 25 %), h/o nsvt s/p icd (replaced 2 years ago), presenting from [**hospital3 **] with nsvt. . . active issues: #. nsvt: likely etiology is scarring from previous mis v. cardiomyopathy. pt has defibrillator in place that was investigated upon admission. pt was on amiodarone in the past, which worked well for her initially but then discontinued its use in [**month (only) 547**] due to adverse side effects. only symptom has been palpitations. before her ep study, pt's symptoms and ectopy were managed adequately with a lidocaine drip. incidence of nsvt decreased, but the patient continued to have some pvcs and couplets. an ep study was performed, which showed dense scar along the inferior wall from mid-wall to apex extending to the infero-lateral wall and distal septum. the base of the heart was normal. pes with up to triple extra-stimuli induced only pleomorphic vt that --> to vfl --> external shocks. the pt had multiple vt morphologies induced with cath manipulation and burst pacing. the clinical vt was not induced and ablation was therefore not performed. pt was continued on metoprolol, and then started on quinidine and mexilitine after the ep study, with good control of pt's symptoms and no more ectopy on telemetry. . . chronic issues: # cad: pt's history of cad includes 3 mis and cabg x2 in [**2126**] and [**2132**]. she is on nitroglycerin at home for chest pain, but did not need it during the hospitalization. she was continued on her home lipitor and ezetimibe. . # htn: documented history of this problem, for which she had been treated with hydralazine, isosorbide, and lopressor prior to admission. however, she was slightly hypotensive in-house, and so her home hydralazine and isosorbide were held, but she was continued on her home lopressor. before discharge, she was transitioned to long-acting lopressor that she will take twice daily. pt has adverse reaction to ace inhibitors, more specifically lisinopril as she develops severe mouth sores (so bad she stopped taking all of her medicines). there was some thought about starting her on diovan, but due to her adverse reaction to ace inhibitors (and their relationship to arbs), she was simply continued on lopressor and her isosorbide and hydralazine were held. . # chronic systolic heart failure: documented history of this problem. [**name (ni) **] during this admission showed an ef of 25%. on hydralazine and isosorbide at home but was held in-house. . # hld: documented history of this problem. pt was continued on home lipitor and ezetimibe. . # anxiety: documented history of this problem. pt was continued on home oxazepam. . transitional issues # pt's isosorbide and hydralazine were held during the hospitalization due to low blood pressures. recommend re-checking blood pressures at home and in her pcp's office to determine the need to re-start these medications. medications on admission: atorvastatin [lipitor] 20 mg tablet, 1 tablet po bid ezetimibe [zetia] 10 mg tablet, 1 tablet po daily hydralazine hcl 10mg tablet, 1 tablet po tid isosorbide dinitrate 20 mg tablet, 1 tablet po tid lopressor 50mg tablet, 1 tablet po tid nitroglycerin - 0.4 mg tablet, sublingual - as directed once a day triamcinolone acetonide - 0.1 % cream - as directed once a day oxazepam 30mg tablet, 1 tablet po tid discharge medications: 1. quinidine gluconate 324 mg tablet extended release sig: one (1) tablet extended release po q8h (every 8 hours). disp:*90 tablet extended release(s)* refills:*2* 2. mexiletine 150 mg capsule sig: one (1) capsule po q12h (every 12 hours). disp:*60 capsule(s)* refills:*2* 3. atorvastatin 20 mg tablet sig: one (1) tablet po bid (2 times a day). 4. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 5. oxazepam 30 mg capsule sig: one (1) capsule po three times a day. 6. magnesium oxide 400 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 7. metoprolol succinate 25 mg tablet extended release 24 hr sig: three (3) tablet extended release 24 hr po bid (2 times a day). disp:*180 tablet extended release 24 hr(s)* refills:*2* 8. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 9. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) tablet sublingual as directed as needed for chest pain. discharge disposition: home discharge diagnosis: ventricular tachycardia chronic systolic congestive heart failure coronary artery disease depression discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure caring for you at [**hospital1 18**]. you were admitted with palpitations caused by ventricular tachycardia and needed to get intravenous medicine to control the arrhythmias. an ablation was attempted by dr. [**last name (stitle) **] but he was not able to complete this procedure because the heart rhythm that caused the palpitations was not able to be induced during the procedure. therefore, you have been started on 2 new medicines to control the arrythmias, mexilitine and quinidine. so far, these medicines seem to be working well for you. please check your blood pressure at home to make sure you are tolerating the medicines. . we made the following changes to your medicines: 1. start taking mexilitine and quinidine gluconate to control your ventricular tachycardia 2. change the metoprolol to succinate, a long acting version and take only twice daily 3. stop taking isosorbide mononitrate (imdur) and hydralazine for now, talk to dr. [**last name (stitle) **] about restarting these medicines at your next appt. 4. eat a banana and drink [**location (un) 2452**] juice every day with breakfast to keep your potassium level high. 5. start taking magnesium tablets twice daily to increase your magnesium levels followup instructions: . department: cardiac services when: monday [**2150-1-5**] at 11:00 am with: icd call transmissions [**telephone/fax (1) 59**] building: none none campus: at home service best parking: none . name: bright,mark t. specialty: fmily medicine location: [**hospital **] health center address: 200 [**last name (un) 12504**] dr, [**location (un) **],[**numeric identifier 18464**] phone: [**telephone/fax (1) 18462**] **we are working on a follow up appointment with dr. [**last name (stitle) **] within 1 week. you will be called at home with the appointment. if you have not heard from the office within 2 days or have any questions, please call the number above** department: cardiac services when: friday [**2150-1-2**] at 1:40 pm with: [**name6 (md) **] [**name8 (md) **], md [**telephone/fax (1) 62**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) **] campus: east best parking: [**hospital ward name 23**] garage [**name6 (md) **] [**name8 (md) **] md [**md number(2) 11975**]",1
35,"admission date: [**2113-8-1**] discharge date: [**2113-8-6**] date of birth: [**2066-9-20**] sex: m service: medicine allergies: labetalol attending:[**first name3 (lf) 1493**] chief complaint: headache, high blood pressure major surgical or invasive procedure: renal ultrasound history of present illness: 46 yom with hx of chronic hepatitis c, cirrhosis, hcc, s/p cadaveric liver transplant 6/[**2110**]. liver biopsy performed in [**2112-8-12**] showed signs of reactivation of hepatitis c and patient was restarted on ribavarin and interferon in [**month (only) 404**] [**2112**]. pt was found to be hypertensive at hepatology appt today with bp of 198/133 despite metoprolol, labetalol and sl nitrate and was then sent to the er. pt also reports constant headache which began 5 days ago. ha is frontal pounding type headache. pain ranges [**2116-1-20**] and is relieved partially with tylenol. no photophobia, no visual changes, no diplopia. pt reports weakness and fatigue x 2 weeks which began after initiation of cyclosporine treatment. denies cp, sob, palpitations, fevers/chills, diaphoresis, diarrhea. + urinary frequency, no dysuria. . in er, pt with bp 159/125, hr 72, rr 18, t 97.1, o2sat 100%. pt continued with elevated bp to 230/130's, responded minimally to sublingual nitro and minimal resonse to labetalol but did have adverse reaction to labetolol with flushing and rash. pt placed on nitro drip. . past medical history: hep c hepatocellular ca hypertriglyceridemia htn . psh: liver transplant sinus surgery social history: sh: + tobacco 3 pack years, quit 24 years ago negative etoh, no ivda pt is part owner of computer technology business . family history: fh: mother with htn, brain aneurysm father with [**name2 (ni) **] ca brother with cabg x 4 . physical exam: v/s: t 97.3 bp 168/111 hr 83 rr 12 gen: nad heent: eomi, perrla, oropharynx clear cvs: +s1, +s2, no m/r/g, rrr lungs: ctab abd: +bs, nt/nd, +ruq scar ext: no peripheral edema, +2 pulses distally neuro: cn ii-xii intact, 5/5 strength all extremities, sensation intact, no babinski pertinent results: [**2113-8-1**] 03:50pm pt-14.1* ptt-30.6 inr(pt)-1.3* [**2113-8-1**] 03:50pm plt smr-very low plt count-60* [**2113-8-1**] 03:50pm hypochrom-1+ anisocyt-1+ poikilocy-occasional macrocyt-1+ microcyt-normal polychrom-normal ovalocyt-occasional [**2113-8-1**] 03:50pm neuts-76* bands-0 lymphs-12* monos-11 eos-1 basos-0 atyps-0 metas-0 myelos-0 [**2113-8-1**] 03:50pm wbc-3.0* rbc-3.49* hgb-10.6* hct-32.7* mcv-94 mch-30.5 mchc-32.4 rdw-17.9* [**2113-8-1**] 03:50pm ck-mb-notdone ctropnt-<0.01 [**2113-8-1**] 03:50pm lipase-32 [**2113-8-1**] 03:50pm alt(sgpt)-16 ast(sgot)-31 ck(cpk)-57 alk phos-53 amylase-99 tot bili-1.4 [**2113-8-1**] 03:50pm estgfr-using this [**2113-8-1**] 03:50pm glucose-79 urea n-37* creat-2.4*# sodium-138 potassium-4.7 chloride-103 total co2-23 anion gap-17 [**2113-8-1**] 08:00pm urine hyaline-0-2 [**2113-8-1**] 08:00pm urine rbc-0 wbc-0-2 bacteria-rare yeast-none epi-0 [**2113-8-1**] 08:00pm urine blood-mod nitrite-neg protein-100 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg [**2113-8-1**] 08:00pm urine color-yellow appear-clear sp [**last name (un) 155**]-1.017 [**8-1**] ct-head w/o contrast: impression: no evidence of acute intracranial hemorrhage or mass effect. [**8-1**] cxr: impression: no acute cardiopulmonary process [**8-1**] renal u/s: impression: blunted arterial upstrokes with somewhat decreased resistive indices in both kidneys. this pattern can be seen in renal artery stenosis. further evaluation with an mra or cta could be performed on a nonemergent basis. [**8-1**] ekg: sinus rhythm prominent q wave in avf - is nonspecific and may be normal variant. modest nonspecific low amplitude lateral t waves clinical correlation is suggested. since previous tracing of [**2111-5-25**], st-t wave abnormalities decreased brief hospital course: 46 yom with hx of hep c, hcc, s/p liver transplant now with reactivation hep c who presents to er with hypertensive emergency. . 1) hypertensive emergency: pt presented to liver clinic on [**8-1**] with bp in 190's/130's which did not respond to metoprolol, labetalol and sl nitrate. pt sent to the er for bp control. in the er patient found to have elevated cr 2.4, which is above baseline of 1.0-1.3. pt also with headaches x 5 days which was attributed to elevated blood pressures. there are no focal neurologic deficits. ct scan of the head was negative for hemorrhage or mass effect. renal u/s ordered to evaluate for ras, which did show blunted arterial upstrokes which can be seen in ras. pt then transferred to micu for bp control. cause of hypertensive emergency likely due to meds vs. renal artery stenosis. pt began cyclosporine 2 weeks ago and now presents with htn and arf, which are both adverse side effects of this medication. renal u/s today suggestive of ras. patient on nitro drip on icu, which was weaned prior to transfer to medical floor. patients cyclosporine was discontinued, patient bp stable on metoprolol 150 [**hospital1 **], cardura 4mg [**hospital1 **]. patient will have mra of kidney as outpatientto further evaluate renal artery stenosis once creatinine back at baseline. . 2) arf: pt with cr of 2.4 on admission, baseline is 1.0-1.3. etiology is likely htn emergency [**1-13**] ras vs. cyclosporine. pt also on many medications, so urine sediment and eosinophils sent which ewre negative. cyclosporine discontinued, lisinprol held. . 3) liver transplant: pt with transplant in [**2111-5-13**] [**1-13**] hep c cirrhosis and hcc. pt now with reactivation hep c on ribavirin and interferon. cylcosporine discontiued, and rapamycin started at 2mg. patient rapamycin level subtherapeutic day of discharge, so given 4mg. he will follow up at liver clinic day after discharge for repeat rapamycin level. cellcept continued. medications on admission: . meds: -protonix 40mg qdaily -caltrate 600mg [**hospital1 **] -metoprolol 150mg [**hospital1 **] -cellcept 500mg [**hospital1 **] -lisinopril 40mg qdaily -ambien 12.5 mg qhs temazepam 30mg qhs prn peg interferon alpha 2 a, 135 mcg once per week ribavarin 400mg [**hospital1 **] cardura 2mg qdaily -tricor 48mg qdaily procrit 60,000 units daily neoral 150mg po bid bactrim daily . 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. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 4. metoprolol tartrate 50 mg tablet sig: three (3) tablet po bid (2 times a day). disp:*180 tablet(s)* refills:*2* 5. fenofibrate micronized 48 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. mycophenolate mofetil 500 mg tablet sig: one (1) tablet po bid (2 times a day). 7. zolpidem 5 mg tablet sig: two (2) tablet po hs (at bedtime). 8. doxazosin 4 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 9. trimethoprim-sulfamethoxazole 80-400 mg tablet sig: one (1) tablet po daily (daily). 10. temazepam 15 mg capsule sig: two (2) capsule po hs (at bedtime) as needed. 11. sirolimus 1 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: primary: hypertensive urgency acute renal failure . secondary chronic hep c hyperlipidemia hepatacellular ca (h/o) discharge condition: stable discharge instructions: you came to the hospital with very high blood pressure that was difficult to control. we changed your antihypertensives and will give you prescriptions for your new medications. this is likely due do the medication you were on for your liver transplant. we have changed those medications. . you also had kidney abnormalities, including a stenosis of one of the renal arteries, which may have contributed to the hypertension. we sugguest that you f/u for a ct angiogram once your kidney function has normalized. . please f/u with your hepatologist early this week. followup instructions: please f/u in the liver clinic tomorrow, where they wil draw a fasting sirolimus level. . please f/u with your pcp about getting further imaging of your kidney. completed by:[**2113-8-14**]",1
36,"admission date: [**2161-5-16**] discharge date: [**2161-5-21**] date of birth: [**2096-2-18**] sex: m service: cme history of present illness: the patient is a 65-year-old male with a past medical history of cad, nqwmi, status post two vessel cabg plus avr ([**2148**]) and dc cardioversion, [**2161-5-14**], who presented to the er with a two-day history of dyspnea and pnd. the patient has a history of atrial fibrillation and underwent dc cardioversion on [**2161-5-14**]. the patient was hypotensive following the cardioversion and required per report up to 7 liters of saline, accompanied by a weight change of approximately 9 pounds (from 186 pounds to 195 pounds). the patient states that he was feeling well prior to the dc cardioversion and that subsequently had dyspnea on exertion as well as shortness of breath at rest. the patient stated that he had approximately 3-4 episodes of pnd over the 2 nights prior to admission. he also had 1 brief episode of substernal chest pain that lasted 2-3 minutes the day prior to admission at 2:00 p.m. that began when he went from a sitting to a standing position and resolved spontaneously. he describes the chest discomfort as central, substernal, sharp, non-radiating, non-pleuritic and this is not associated with diaphoresis, palpitations, nausea or vomiting. he does deny lower extremity edema and denies having any significant history of angina since his cabg in [**2148**]. on further review of systems, the patient admits to having upper respiratory tract infection symptoms over the past 3-4 days including cough productive of clear white sputum. there were no fever, chills, diarrhea, headache, rash or arthralgia. the patient, of note, has a significant etoh history and drinks up to 8 beers per day. his last drink was at 6:00 p.m. on the day prior to admission. in the emergency department the patient received 40 mg of lasix, supplemental oxygen, 325 mg of aspirin and was started on nitroglycerin drip. his ecg showed sinus bradycardia with pr prolongation, as well as left ventricular hypertrophy and atrioventricular conduction delay and diffused st and t-wave changes, (there was no significant change in comparison with the prior ecg of [**2161-5-14**]). the patient's chest film was consistent with mild chf. an echocardiogram revealed mild symmetric lvh with an ef of 50 to 55 percent and mechanical aortic valve prosthesis with 1 plus ar and 1 plus mr. past medical history: status post coronary artery bypass graft in [**2148**] at the [**location (un) 511**] [**hospital **] hospital. he had an svg to the lad and svg to the om. this procedure was done in complement to an aortic valve replacement. per report, the patient received a st. [**male first name (un) 1525**] number 23 mechanical valve for treatment of the aortic value stenosis. per report, the patient had non-q wave mi in [**2143**]. paroxysmal atrial fibrillation, status post dc cardioversion on [**2161-5-14**] as well as on [**2161-2-26**]. right parietal cva in [**1-20**] with no residual symptoms. hyperlipidemia. diabetes mellitus, insulin dependent type 2 diabetic with retinopathy. he is followed by the [**hospital **] clinic. the patient reports that he checks sugars 6-7 times per day and gives himself regular though no longer, i think, insulin. he had an a1c at 8.3 on most recent check. status post herniorrhaphy meckel diverticulum. gerd. significant ethanol use. no history of dts or seizures. allergies: the patient has no known drug allergies. medications on admission: 1. hydrochlorothiazide 25 mg (increased from 12.5 mg). 2. atenolol 25 mg q.a.m. 3. lisinopril 20 mg q.a.m. 4. coumadin 5 mg every tuesday, thursday, saturday; 6 mg every sunday, monday, wednesday, friday. 5. lipitor 80 mg q.d. 6. aspirin 81 mg q.d. 7. zantac 150 mg p.r.n. social history: the patient is married and lives with his wife. [**name (ni) **] is a former smoker with an approximate 20-pack year history. the patient quit several years ago. he also drinks up to 8-9 beers per day though he states that he has cut down to 2 beers per day. denies any illicit drug use. the patient is a gambler and former boxer. he won a lottery several years ago. family history: noncontributory. physical examination on admission: temperature is 97.5 degrees, heart rate is 50, blood pressure initially 171/71 and decreased to 129/69 with nitroglycerin, respiratory rate 16, oxygen saturation 95 percent on room air. the patient is found sitting in bed awake in no acute distress. heent: nc/at. sclerae are anicteric. pupils are equally round and reactive to light. extraocular muscles are intact. mucous membranes are moist. oropharynx is clear. neck is supple, there are no bruits. jvd is 10-11 cm at 45 degrees. 2 plus pulses bilaterally. heart: regular rate. no bradycardiac rhythm with a 1/6 systolic ejection murmur at the right upper sternal border. the patient has bilateral diminished breath sounds at the bases, as well as bilateral rales at the bases bilaterally. there are no wheezes. abdomen is obese and soft, nontender, nondistended. normoactive bowel sounds. liver is palpable. the liver is approximately 10 cm to 11 cm at the mid clavicular line. rectal examination reveals guaiac-negative brown stool. extremities are warm and dry, there is trace pitting edema at the ankles bilaterally. neurological examination: the patient is awake, alert and oriented x3. speech is normal. cranial nerves ii to xii are intact. strength 5 plus in the upper and lower extremities. normal cerebellar examination. laboratory data on admission: white count is 12.3, hematocrit is 42, platelets are 291. sodium 136, potassium 3.8, chloride 92, bicarbonate 28. bun 18 creatinine 1.2, glucose 210. tsh 3.1, troponin t 0.19 with a ck of 295 and mb of 6. ua is nitrite negative. ecg shows sinus bradycardia, 45 beats per minute, normal axis. pr interval of 272 milliseconds, [**street address(2) 4793**] elevations in v1 and v2, q-wave inversions in v3, avf, and v6. chest film demonstrates mild chf. hospital course: cad. serial cardiac enzymes were obtained given the patient's history of chest pressure prior to admission. the patient's initial troponin t was 0.19 and increased subsequently to 0.21. however, his ck was 295 and subsequently decreased to 188. his ck-mb was initially 6, decreased to 4. as the patient is status post recent cardioversion and also has mild cri, i felt that his troponin elevation may well be due to both renal insufficiency as well as recent cardioversion. the patient underwent exercise tolerance test in which he carried out a modified [**last name (un) 20758**] treadmill test with a 70 percent target heart rate achieved (heart rate reached at 109 with a blood pressure of 180/110). there were no anginal symptoms or ekg changes with the baseline abnormalities at maximum workload. nuclear imaging revealed a mild reversible defect of the inferior wall. resting perfusion images did show resolution of this defect. ejection fraction was approximately 50 percent. there was lack of septal translation consistent with his prior cabg. the patient was restarted on atenolol though at a lower dose of 12.5 mg q.d. he was maintained on atorvastatin 80 mg q.d. as well as on the aspirin. his lisinopril dose was increased to 40 mg q.d. atrioventricular conduction delay. the patient was noted to have an elevated qt and qtc. his magnesium and potassium were repleted aggressively. his qtc on the day of discharge was 409 with a qt of 520. his hydrochlorothiazide was switched to aldactazide. he will take one-half tab q.d. for a total of 12.5 mg of hydrochlorothiazide and 12.5 mg of aldactone. he will also begin taking magnesium oxide 400 mg q.d. supplementation. the patient was asked and recommended on several occasions to undergo holter monitoring subsequent to discharge. however, the patient states that he is not willing to have a holter monitor over the next several weeks and will consider undergoing holter monitoring at his next visit with his cardiologist. chf. as mentioned in the hpi, the patient received significant fluid resuscitation following his recent cardioversion. the patient was aggressively diuresed back to his baseline weight. the patient reported resolution of his symptoms of shortness of breath, pnd and dyspnea on exertion. the patient's weight remained stable for several days prior to discharge. atrial fibrillation. the patient remained in sinus rhythm during the hospitalization. his is monitored on telemetry, and he is noted to stay in sinus rhythm. he was maintained on anticoagulation with coumadin both for his atrial fibrillation and for his mechanical aortic valve with target inr of 2.5 to 3.5. the patient was begun on disopyramide, on the day prior to discharge, he was loaded with 300 mg and ekg on the day of discharge did not reveal any significant change in qtc interval. the patient did not appear to have any adverse reactions to disopyramide and did have any urinary retention. the patient was explained at length in detail every possible side effect of the disopyramide including urinary retention and will contact his physician if he experiences any of the side effects. bradycardia. the patient was noted to be bradycardiac on admission and on several occasions throughout his admission. he improved off atenolol and his atenolol was restarted at the lower dose of 12.5 mg q.d. which he will continue taking after this hospitalization. diabetes mellitus. the patient was maintained on a sliding scale of regular insulin similar to his [**last name (un) **] dosing. [**initials (namepattern4) **] [**last name (namepattern4) **] consult was obtained. the patient was intermittently maintained on nph insulin as well though he prefers to only take regular insulin and on several occasions refused with nph dosing. the patient was noted to have labile blood sugars over this hospitalization though did not allow changes in general from his [**last name (un) **] sliding scale. ethanol abuse. the patient was placed on a ciwa scale given a significant drinking history. however, his ciwas remained zero and required no ativan. elevated lfts. the patient was noted to have significantly elevated liver tests on admission. his alt was 217, his ast was 192, alkaline phosphatase was 156 and his bilirubin total was noted to be 0.8. subsequent lfts revealed improvement in these values. lfts diminished to 73 with an ast of 28 and alkaline phosphatase of 112. it is likely that these abnormalities were related to his alcohol intake (though the alt greater than ast is somewhat atypical). it is recommended that the patient have followup lfts on an outpatient basis. the patient is discharged in stable condition. discharge diagnoses: coronary artery disease, status post coronary artery bypass graft. aortic stenosis status post mechanical aortic valve replacement. diabetes mellitus paroxysmal atrial fibrillation status post cardioversion. congestive heart failure. hyperlipidemia. atrioventricular conduction delay. the patient will follow up with dr. [**first name (stitle) **] a. f. [**doctor last name 73**] on [**2161-6-15**] at 11:30 a.m. he will also follow up with his primary care physician, [**last name (namepattern4) **]. [**first name11 (name pattern1) **] [**initial (namepattern1) **] [**last name (namepattern4) **], in two weeks if discharged and will also be the followed by the [**hospital 197**] clinic. medications on discharge: 1. ranitidine 150 mg b.i.d. 2. lisinopril 40 q.d. 3. atenolol 12.5 q.d. 4. disopyramide 150 mg p.o. b.i.d. 5. aldactazide 12.5/12.5 mg q.d. 6. magnesium oxide 400 q.d. 7. aspirin 81 q.d. 8. humulin insulin as directed per his [**last name (un) **] sliding scale. 9. lipitor 80 mg q.d. 10. coumadin 5 mg tuesday, thursday, saturday; 6 mg on the other days. [**doctor first name **] [**initials (namepattern4) **] [**name8 (md) **], [**md number(1) 20759**] dictated by:[**last name (namepattern1) 8188**] medquist36 d: [**2161-5-21**] 16:06:49 t: [**2161-5-23**] 03:44:04 job#: [**job number 11233**]",0
37,"admission date: [**2112-7-2**] discharge date: [**2112-8-11**] date of birth: [**2045-12-30**] sex: m service: medicine allergies: no known allergies / adverse drug reactions attending:[**first name3 (lf) 7591**] chief complaint: fever, hypotension major surgical or invasive procedure: [**2112-7-2**] intubation history of present illness: mr. [**known lastname 34698**] is a 66 year old man with h/o poems syndrome, s/p autosct [**12-15**], therapy-related mds, recently hospitalized and diagnosed with recurrence of poems syndrome, c1d18 of velcade/dexamethasone, who was admitted with fever and hypotension. the patient was discharged 2 days prior to admission ([**2112-6-30**]) after hospitalization for febrile neutropenia, complicated by arf requiring hdx4 sessions and features of poems syndrome relapse. at home, the patient had a low grade temp yesterday to 100.3 with chills and then another fever to 101.2 this afternoon. the wife notes that he was complaining of increased pain in his lower extremities (neuropathy) and had decreased po intake. he became increasingly lethargic and weak to the point that they had difficulty getting him out of bed. his urine output decreased from 1100cc the day before to 400cc over 24h. foley was in place since last sunday (1 week). the wife called the bmt fellow on call, who referred the patient to the ed. in the field, the patient's bp was 60/40. ems placed a peripheral line and bolused him with ivf. in the ed, initial vs were: t 101.2 hr 120 bp 184/132 rr 18 o2sat 100% nrb. bp then dropped to 50/30 about 10 minutes after arrival. the patient was lethargic, but arousable to voice, complaining of generalized body pains. patient had brown, turbid urine in his foley. cxr showed persistent l basilar opacification. labs notable for hct 19.5, plt 8, hco3 18, cr 3.7. the patient was started on levophed, vanc, and cefepime. also given a dose of hydrocortisone given recent steroid use. given 4l ns. he was intubated in the ed without difficulty using the bougie, despite h/o tracheal stenosis, and started on fent/midaz for sedation. on transfer, levophed was running at 0.42mcg. vs: t 100 hr 119 bp 114/51 rr 18 o2sat 99% on fio250% tv450 peep4. on arrival to the micu, patient's vs t 98.6 hr 106 bp 127/84 rr 16 o2sat 98% on ac tv 450 rr 18 fio2 40% peep 5. the patient is intubated and sedated on fentanyl 100mcg/hr, midazolam 4mg/hr, levophed 0.32mcg/kg/min. past medical history: oncologic history: poems syndrome manifested by polycythemia, polyneuropathy, organomegaly, endocrinopathies including hypocalcemia, hypothyroidism, hypogonadism and elevated pth (diagnosed in [**2099**]). in [**2101**] anasarca that eventually progressed to respiratory failure, treated with plasmapheresis and prednisone followed by 18 months of cyclophosphamide. [**4-/2108**]/[**2108**]: bortezomib (1.3 mg/m2 days 1,4,8,11 and dexamethasone (20 mg days 1,2,4,5,8,9, 11, and 12) x three cycles discontinued due to painful lower extremity neuropathy. [**11/2108**] high dose cytoxan for stem cell mobilization ([**11/2108**]) [**12/2108**] high dose melphalan with stem cell rescue ([**2108-12-9**]) in remission since than. [**4-/2112**]: bone marrow aspirate and biopsy showed dysplastic basophilic and polychromatophilic erythroblasts, a marked left shift and dysplastic myelopoiesis and abundant hyperchromic megakaryocytes, which initially were felt to be consistent with colchicine toxicity; however, chromosome studies performed on that bone marrow material revealed an abnormal karyotype 15/16 studied cells showed a complex clone with the following anomalies. he had deletion in the long arm of chromosome 5 between band 5q13 and 5q33, otherwise known as 5q minus. he had monosomy 13, monosomy 17, monosomy 20, and addition of an unidentified marker chromosome and [**2-12**] double minute chromosomes. these were all consistent with a myeloid abnormality since there were not an increased number of blasts much more consistent with mds. other past medical history: 1. poems syndrome: first diagnosed in [**2099**] with treatment described above. his manifestations have been as follows: a. polyneuropathy - cidp in [**2099-6-6**]; painful lower extremity sensory neuropathy and proprioception defects. b. organomegaly - splenomegaly c. endocrinopathy - hypothyroidism, hypogonadism, hypocalcemia related to hypoparathyroidism d. monoclonal gammopathy e. skin and nail changes - now resolving. f. pulmonary hypertension and restrictive lung disease. g. chronic renal insufficiency (which has now resolved with therapy) h. anasarca, now resolved. i. hyperuricemia and gout - now resolved j. polycythemia and thrombocythemia - now resolved 2. vitamin b12 deficiency 3. s/p compound fracture, [**2103-8-7**] 4. s/p tracheostomy [**2101**] 5. prostate cancer s/p brachytherapy 6. gout 7. pulmonary htn and restrictive lung disease 8. chronic kidney disease 9. c dif ([**5-/2112**]) 10. acute angle glaucoma ([**2112-4-27**]) social history: pt is a ukrainian refugee who immigrated to the us in [**2049**]. he lives with his wife and they have two sons. [**name (ni) **] cigarettes, very occasional alcohol. he works as a paint salesman for [**last name (un) 34699**]-[**location (un) 805**]. he is also a [**country 3992**] veteran. exposed to [**doctor last name **] [**location (un) **], which he believes is the etiology of his poems. family history: mother is alive and has sle, fibromyalgia. his father's medical history is unknown. half-sister with ovarian cancer. physical exam: admission exam vs: tm 98.7, tc 98.7, p 98 (98-106), bp 117/70 (117/70 - 127/84), rr 16 spo2: 98%, fio2: 40% ventilator mode: cmv/assist/autoflow, vt: 450 ml, rr : 18, peep: 5 cmh2o general: intubated, sedated heent: sclera anicteric, pupils minimally reactive to light, l>r neck: supple, jvp not elevated, no lad cv: tachycardic, s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation anteriorly with decreased breath sounds at the bases abdomen: soft, non-distended, bowel sounds present gu: foley with brown, turbid urine ext: warm, well perfused, 2+ pulses, 2+ generalized edema/anasarca neuro: sedated discharge physical exam: 98.1, 120/68, 74, 18, 98ra general: aaox3 in nad, [**last name (un) 4969**] appearing male older than stated age heent: pupils are asymmetric at baseline l>r neck: previous scar from trach is well healed, no elevated jvp no lad lungs: ctab moving good air bilaterally cv: rrr, 2/6 systolic murmur heard best at hte lusb not radiating abd: mildly protuberant, normoactive bowel sounds, soft, nontender, no palpable masses ext: warm, well perfused, trace peripheral edema bilaterally skin: two stage 1 ulcers. one located on the right buttock with some underlying edema, and one located on the right posterior posterior heel neuro: cn ii-xii intact. motor 3/6 strength in ue and le bilaterally. decreased proximal strength biltaerally int he lower extremiteis. sensation grossly intact and symmetric. occasional intentional tremulous not orthostatic, patient is symptomatic upon standing but by 5min patients vs are stable. pertinent results: admission labs [**2112-7-2**] 08:40pm blood wbc-3.4* rbc-2.16* hgb-6.3*# hct-19.5* mcv-90 mch-29.2 mchc-32.4 rdw-15.1 plt ct-10*# [**2112-7-2**] 08:40pm blood neuts-54 bands-10* lymphs-5* monos-30* eos-0 baso-0 atyps-0 metas-0 myelos-1* [**2112-7-2**] 08:40pm blood pt-13.5* ptt-22.8* inr(pt)-1.3* [**2112-7-2**] 08:40pm blood glucose-71 urean-75* creat-3.7*# na-133 k-4.2 cl-101 hco3-18* angap-18 [**2112-7-2**] 08:40pm blood alt-47* ast-32 ld(ldh)-219 alkphos-272* totbili-1.1 [**2112-7-2**] 08:40pm blood ctropnt-0.06* [**2112-7-3**] 04:24am blood ck-mb-4 ctropnt-0.07* [**2112-7-3**] 09:48am blood ck-mb-3 ctropnt-0.08* [**2112-7-2**] 08:40pm blood albumin-2.8* [**2112-7-3**] 04:24am blood calcium-6.5* phos-5.3*# mg-1.5* [**2112-7-2**] 09:08pm blood lactate-2.2* micro [**2112-7-2**] urine culture (final [**2112-7-4**]): no growth. [**2112-7-2**] blood culture, routine (preliminary): staphylococcus species. aerobic bottle gram stain (final [**2112-7-3**]): gram positive cocci in pairs and clusters. anaerobic bottle gram stain (final [**2112-7-4**]): gram positive cocci in pairs and clusters. [**2112-7-2**] blood culture, routine (pending): [**2112-7-3**] sputum source: endotracheal. gram stain (final [**2112-7-3**]): [**12-1**] pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (preliminary): rare growth commensal respiratory flora. [**2112-7-3**] blood culture: neg [**2112-7-4**] blood culture, neg [**2112-7-4**] blood culture, neg urine studies: [**2112-7-20**] 06:05am urine casthy-20* castbr-2* [**2112-7-9**] 02:09pm urine histoplasma antigen-test [**2112-7-11**] 04:57pm urine bk virus by pcr, urine-test [**2112-7-11**] 06:23am urine u-pep-multiple p ife-no monoclo [**2112-7-27**] 09:13am other body fluid wbc-650* rbc-[**numeric identifier **]* polys-2* bands-1* lymphs-12* monos-26* mesothe-1* macro-58* urine: [**2112-8-8**] 05:30pm urine color-yellow appear-clear sp [**last name (un) **]-1.012 [**2112-8-8**] 05:30pm urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-neg [**2112-8-8**] 05:30pm urine rbc-1 wbc-2 bacteri-none yeast-none epi-1 imaging [**2112-7-2**] chest (portable ap): persistent left basilar opacification may represent atelectasis, pneumonia or aspiration. moderate-sized left and small right bilateral pleural effusions. possible mild pulmonary vascular congestion, though evaluation is somewhat limited due to low lung volumes. [**2112-7-4**] chest (portable ap): there is an endotracheal tube and a feeding tube which are unchanged in position. there is also a right-sided central venous line with the distal lead tip in the cavoatrial junction, unchanged. there is unchanged cardiomegaly. there is a left retrocardiac opacity and left-sided pleural effusion which is stable. no overt pulmonary edema is identified. overall, there has been no significant change. [**2015-7-8**]: ct abd/pelvis: impression:1. no new fluid collection or source of intra-abdominal infection. 2. stable bilateral small to moderate partially loculated pleural effusions slightly improved since [**2112-6-11**]. [**2112-7-11**]: ruq u/s impression: 1. no evidence of portal venous thrombosis. 2. no hepatobiliary pathology. 3. borderline spleen size. [**2112-7-17**]: ct chest impression: 1. progression of left lower lobe consolidation, and increase in size in bilateral loculated pleural effusions with enhancing pleura, concerning for pneumonia and/or empyema. 2. cardiomegaly. 3. heterogeneous enhancement of the kidneys, bilateral, raises possibility of pyelonephritis or infarct, recommend correlation with ua. [**2112-7-27**]: bronchial washing: bronchial lavage: negative for malignant cells. pulmonary macrophages and blood. no viral cytopathic changes or fungal organisms are seen. [**2112-7-29**]: hip xray:views of both hips show minimal hypertrophic spurring with slight narrowing of the joint spaces bilaterally. multiple metallic seeds are seen in the region of the prostate. [**2112-8-2**]: ultrasound right buttock: persistent mild edema of the soft tissue overlying the right buttock. no drainable collection identified. discharge labs [**2112-8-11**] 12:00am blood wbc-2.3* rbc-2.37* hgb-7.2* hct-21.7* mcv-92 mch-30.3 mchc-33.1 rdw-14.3 plt ct-40* [**2112-8-11**] 12:00am blood neuts-30* bands-0 lymphs-47* monos-19* eos-0 baso-0 atyps-0 metas-0 myelos-4* [**2112-8-11**] 12:00am blood pt-10.3 ptt-22.7* inr(pt)-0.9 [**2112-8-11**] 12:00am blood glucose-130* urean-37* creat-0.6 na-137 k-4.4 cl-101 hco3-28 angap-12 [**2112-8-11**] 12:00am blood alt-52* ast-24 ld(ldh)-293* alkphos-391* totbili-0.4 [**2112-8-11**] 12:00am blood calcium-8.6 phos-3.0 mg-1.8 brief hospital course: primary reason for admission: mr. [**known lastname 34698**] is a 66 year old man with h/o poems syndrome, s/p autosct [**12-15**], therapy-related mds, recently hospitalized and diagnosed with recurrence of poems syndrome, s/p velcade/dexamethasone, who was admitted with fever and hypotension and requiring intubation initially who was found to have b+glucan hemoptysis and multiple episodes of febrile neutropenia requiring multiple icu stays who is currently hemodynamically stable and afebrile x 1 week still requiring occasinal blood transfusions/platelet transfusions at the time of discharge. active issues: #poems- patient with recent diagnosis of poems syndrome relapse velcade/dexameth (d1 [**6-16**]). during this admission he was initially treated with high dose short course of steroids. his pain was controlled with the addition of increased gabapentin, addition of methadone and oxycodone. as his pain would worsen when the steroids were weaned off, he was kepts on 3mg po dexamethasone as a stable dose for one week prior to discharge. while he was on a sliding scale due to being on steroids, he did nto require any insulin and therefore this was stopped at the time of discharge as he was on a stable regimen of steroids. -will require follow-up with dr. [**last name (stitle) 410**] for ongoing care for this -will continue dexamethasone 3mg po bid #mds- patient has history of therapy related mds. his smear during this hospitalization continued to show atypical cells. during this hospitalization he required multiple blood transfusiosn and platelet transfusions and for a period of time was transfusion dependent. he had no adverse reactions to any of his blood product transfusions. he was started on revlimid on [**8-2**] and tolerated this well. he will continue on this after he leaves. -will require frequent lab work to determine if transfusions are required -will continue revlimid 10mg po qday #dysuria- patient has significant dysruia and negative ua with unclear source of the pain. -continue methadone, oxycodone -continue oxybutinin, pyridium and urojets as needed for the pain -consider urology consult if persists neutropenic fevers- no clear source of his fevers. he was found to have hemoptysis and was bglucan positive so was started on voricanozole and continues this at the time of discharge.he was on iv vancomycin and meropenem and these were weaned off in the week prior to discharge and he was switched to ciprofloxacin 500mg po bid a few days prior to discharge and remained afebrile with stable wbc. -continue voricanozole -continue ciprofloxacin # respiratory failure: patient was intubated in the ed to allow for aggressive volume resuscitation. he was extubated without problem and has no oxygen requiremnet at the time of discharge. his lungs are clear on exam. . # acute kidney injury: patient had elevated cr to 3.7 at the beginning of his admission which was a combination of prerenal and atn. this responded to fluids and resolved prior to his discharge. . # elevated troponin: pt had three sets of elevated troponins (0.06, 0.07, 0.08) but ck-mbs were normal. he also had some initial ekg changes that resolved. he likely had some demand ischemia in the setting of [**last name (un) **]. he was chest pain free throughout his course . # anemia: patient is transfusion-dependent [**3-10**] to mds. hct 19.5 on admission, and was transfused 2 units prbcs with an appropriate bump in his hct, which subsequently trended down. he continued to require intermittent transfusions throughout his course. last platelet transfusion on [**2112-8-9**] last prbc transfusion on [**2112-8-11**] . # hyperbilirubinemia: t bili and direct bili were elevated. the rest of his lfts were unremarkable, demonstrating a cholestatic picture. a right upper quadrant u/s was performed that showed no evidence of cholestasis. his alk phos continued to uptrend during the end of his hosptial stay with no localizing symptoms. -this will be monitored by dr.[**doctor last name **] office # volume overload: secondary to new left ventricular dysfunction and acute systolic heart failure as well as poems syndrome with likely capillary leak, hypoalbuminemia, and initial aggressive volume resuscitation. patient was grossly volume overload after his resuscitaion which had resolved at the time of discharge without an elevated jvp or peripehral edema. transitional issues: -patient to receive his own revlimid while at rehab 10mg po qday -pain control- patient is currently on methadone and oxycodone, please monitor for any changes needed -[**name (ni) 34700**] unclear source, on multiple medications medications on admission: ([**2112-6-30**] d/c summary): levothyroxine 112mcg po daily acyclovir 400mg po qhs pyridoxine 100mg po daily doxazosin 8mg po daily vitamin b12 2000mcg po daily thiamine 100mg po daily oxycodone-acetaminophen 5-325mg 1-2tabs po q6h prn calcium carbonate 500mg po bid allopurinol 100mg po daily timolol maleate 0.5% 1gtt [**hospital1 **] citalopram 10mg po daily sulfamethoxazole-trimethoprim 400-80mg po daily gabapentin 300mg po q12h discharge medications: 1. levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). 2. acyclovir 400 mg tablet sig: one (1) tablet po q8h (every 8 hours). 3. vitamin b-12 2,000 mcg tablet extended release sig: one (1) tablet extended release po once a day. 4. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 5. calcium carbonate 500 mg calcium (1,250 mg) tablet sig: one (1) tablet po twice a day. 6. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 7. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 8. gabapentin 300 mg capsule sig: two (2) capsule po q12h (every 12 hours). 9. midodrine 2.5 mg tablet sig: one (1) tablet po tid (3 times a day). 10. dexamethasone 1.5 mg tablet sig: two (2) tablet po q12h (every 12 hours). 11. methadone 5 mg tablet sig: [**2-8**] tablet po qam (once a day (in the morning)). 12. methadone 5 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)): give 12 hours after am methadone dose. 13. oxycodone 5 mg tablet sig: one (1) tablet po q2h (every 2 hours) as needed for severe pain: hold for sedation or rr<10. 14. phenazopyridine 100 mg tablet sig: one (1) tablet po tid (3 times a day) for 2 days. 15. oxybutynin chloride 5 mg tablet sig: one (1) tablet po tid (3 times a day). 16. lidocaine hcl 2 % gel sig: one (1) appl mucous membrane tid (3 times a day) as needed for penile pain. 17. terazosin 1 mg capsule sig: two (2) capsule po hs (at bedtime). 18. revlimid 10 mg capsule sig: one (1) capsule po daily (daily): patient to take own medication. 19. voriconazole 200 mg tablet sig: two (2) tablet po q12h (every 12 hours). 20. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 21. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 22. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 23. hydrocortisone 2.5 % cream sig: one (1) appl rectal daily (daily). 24. ondansetron 8 mg film sig: one (1) film po every 4-6 hours as needed for nausea. 25. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours). discharge disposition: extended care facility: [**hospital1 700**] - [**location (un) 701**] discharge diagnosis: primary: poems, severe sepsis, respiratory failure, mds secondary: bph, type ii diabetes mellitus discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. [**known lastname 34698**], you were admitted to the hospital because you were very short of breath and having fevers. this required you to be in the icu, and after you improved you were transferred to the regular oncology floor. here we worked to help manage your pain and treat your fungal pneumonia with iv antibiotics. on a couple of occasions your blood pressure got low and you were feverish and were treated in the icu for this. as you were here for a prolonged hospitalization you will require intensive rehab to get your strength back and will do this at [**hospital1 **]. while you were here you received multiple blood and platlet transfusions while your counts were low without problems. transitional issues: pending labs/studies: none medications started: voricanozole (antifungal) ciprofloxacin (antibiotic) revlimid dexamethasone oxycodone (as needed pain medication) methadone (pain medication twice a day) senna colace oxybutinin (help with bladder spasm) terazosin (help with bph) pyridium (help with pain on urinating) urojet (numbing medicine for pain with urinatng) midodrine- (for dizziness on standing) ondansetron- as needed for nausea medications changed: increased citalopram from 10mg once a day to 20mg once a day increased gabapentin from 300mg to 600 mg medications stopped: stopped allopurinol stopped doxazosin (on terazosin instead) stopped timolol eye drops (no longer needed) stopped percocets (on oxycodone and methadone instead) follow-up needed for: 1. determine course of antibiotics and antifungals (dr. [**last name (stitle) 410**] 2. monitoring your blood counts and your liver function tests 3. you will need to follow-up with dr. [**last name (stitle) **] to determine if you need your glaucoma drops again followup instructions: will we contact you with your appointment times and dates! if you do not hear from us within 48hours please contact us [**telephone/fax (1) 3241**]",0
38,"admission date: [**2174-10-6**] discharge date: [**2174-10-11**] date of birth: [**2113-11-21**] sex: f service: medicine allergies: ativan / erythromycin base / statins-hmg-coa reductase inhibitors / [**female first name (un) 504**] type anesthetics / bactrim / lidoderm / cleaning chemicals / strog perfume and scents attending:[**first name3 (lf) 783**] chief complaint: shortness of breath, airway obstruction major surgical or invasive procedure: bare metal tracheal stent placement and removal history of present illness: 60 year old female with h/o tracheobronchomalcia s/p trachobronchoplasty in [**6-/2173**] admitted to the medicine service today for observation s/p an elective bronchoscopy with stent placement in cervial trachea. she is awaiting stent removal on [**2174-10-10**]. she was noted to have evidence of severe cervical malacia, severe reflux with supraglottic edema and paradoxical vocal fold motion on laryngoscopy by dr. [**last name (stitle) **] during one of her dyspnea/cyanotic events. . on arrival to the floor, her vitals were stable and she was satting 96% on room air and breathing comfortably. she complained of a sore throat and back pain over her thoracotomy scar. denied any nausea, ha, dizziness, cp, cough, sob. . past medical history: trachael bronchomalacia s/p right thoracotomy with tracheobronchoplasty on [**2173-7-2**] gerd s/p lap toupee fundoplication [**2174-1-21**] coronaray artery disease lad w/< 30% stenosis migraines colonvaginal fistula vaginitis psh: cesarean section x 3 left breast lumpectomy social history: denies tobacco, ethanol and drug use. has exposure to cleaning agents. works for an electrical company. she is married and lives with family family history: mother pancreas ca father siblings ovarian ca offspring other lung ca physical exam: vs: t 97.1, bp 122/82, hr 84, rr 18, sao2 96% ra general: well appearing. nad. heent: mmm. perrl. eomi. neck: supple, no thyromegaly, no jvd. heart: rrr, no mrg, nl s1-s2. lungs: cta bilat, no crackles or wheezes, good air movement, resp unlabored. abdomen: + bs, obese, soft, non-tender, non-distended extremities: wwp, no edema skin: well healed thoracotomy scar on right hemithorax. no rashes or lesions. lymph: no cervical lad. neuro: awake, a&ox3, cns ii-xii grossly intact, muscle strength [**4-21**] throughout, sensation grossly intact throughout. pertinent results: [**2174-10-7**] 06:15am blood wbc-10.4 rbc-4.55 hgb-12.9 hct-39.6 mcv-87 mch-28.4 mchc-32.6 rdw-13.5 plt ct-284 [**2174-10-7**] 06:15am blood pt-12.1 ptt-28.9 inr(pt)-1.0 [**2174-10-7**] 06:15am blood glucose-94 urean-13 creat-0.7 na-142 k-3.6 cl-105 hco3-27 angap-14 [**2174-10-7**] 06:15am blood alt-12 ast-14 ld(ldh)-145 ck(cpk)-32 alkphos-55 totbili-0.5 [**2174-10-7**] 06:15am blood calcium-9.1 phos-4.0 mg-1.9 [**2174-10-9**] 05:57pm blood type-[**last name (un) **] po2-124* pco2-38 ph-7.40 caltco2-24 base xs-0 comment-green top brief hospital course: active issues: # tracheobronchomalacia: patient has h/o tbm. she was on the floor and had a stent placed and then removed as a trial to determine whether she would benefit from sugery. post-operatively she has been stable and weaned from 2 liters oxygen to room air without issue. however, she then developed dyspnea and de-satted to 88% on ra with stridor and rhonchorous breath sounds at which point she was transferred to the micu. she was placed on heliox and was given iv solumedrol and racemic epinephrine. during her first night in the micu, she was tried off heliox and was able to tolerate it for 25 minutes before she began coughing and de-satted to the high 80s. during her second day in the micu, she was taken off heliox and was able to tolerate it. she was monitored for a few hours and did not show any signs of respiratory distress and she was ultimately called out to the floor and started on a po prednisone taper that was to be continued for the next 7 days. on the floor, she was observed overnight and was stable. she was discharged in stable condition with follow up to thoracic surgery and interventional pulmonary. inactive issues: # cad: stable, asymptomatic, continued on asa 81 mg daily . # gerd: stable, continued on pantoprazole . # migraines: stable, asymptomatic and continued on topiramate transitional: [**doctor last name **] of prednisone over the next 4 days. follow up for thoracic surgery to reevaluate tbm restart aspirin medications on admission: acetaminophen-codeine - 300 mg-30 mg tablet - tablet(s) by mouth as needed for as needed for migraines albuterol sulfate - 90 mcg hfa aerosol inhaler - 2 puffs inhaled every four hours as needed for as needed for shortness of breath or wheeze amitriptyline - 10 mg tablet - 1 tablet(s) by mouth at bedtime gabapentin - 600 mg tablet - 1 tablet(s) by mouth three times a day morphine - 30 mg tablet extended release - 1 tablet(s) by mouth at bedtime ondansetron - 4 mg tablet, rapid dissolve - 1 tablet(s) by mouth every eight (8) hours as needed for nausea oxycodone - dosage uncertain oxycodone-acetaminophen [percocet] - dosage uncertain pantoprazole - 40 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth twice a day severe gerd ropinirole - 0.25 mg tablet - 1 tablet(s) by mouth q hs topiramate - 100 mg tablet - tablet(s) by mouth [**hospital1 **] zolpidem - 5 mg tablet - [**12-19**] tablet(s) by mouth qhs prn medications - otc aspirin - 81 mg tablet, delayed release (e.c.) - 1 tablet(s) by mouth daily multivitamin 1 tablet daily discharge medications: 1. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 2. gabapentin 400 mg capsule sig: two (2) capsule po q8h (every 8 hours). 3. morphine 30 mg tablet extended release sig: one (1) tablet extended release po qhs (once a day (at bedtime)). 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. disp:*qs tablet(s)* refills:*0* 5. docu soft 100 mg capsule sig: one (1) capsule po twice a day. disp:*60 capsule(s)* refills:*0* 6. amitriptyline 10 mg tablet sig: one (1) tablet po hs (at bedtime). 7. prednisone 10 mg tablet sig: 1-4 tablets po once a day for 4 days: please take 4 tabs on day 2, 3 tabs on day 3, 2 tabs on day 4, 1 tab on day 5. disp:*qs tablet(s)* refills:*0* 8. multivitamin tablet sig: one (1) tablet po daily (daily). 9. zolpidem 5 mg tablet sig: 1-2 tablets po hs (at bedtime) as needed for insomnia. 10. topiramate 100 mg tablet sig: one (1) tablet po bid (2 times a day). 11. ropinirole 0.25 mg tablet sig: one (1) tablet po qpm (once a day (in the evening)). 12. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 13. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q8h (every 8 hours) as needed for nausea. 14. racepinephrine 2.25 % solution for nebulization sig: 0.5 ml inhalation q4h (every 4 hours) as needed for 5 days: hold for tachycardia (hr >120) or no respiratory distress . disp:*qs ml(s)* refills:*0* 15. aspir-81 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. discharge disposition: home discharge diagnosis: tbm s/p stent placement and removal trachael bronchomalacia s/p right thoracotomy with tracheobronchoplasty on [**2173-7-2**] gerd s/p lap toupee fundoplication [**2174-1-21**] coronaray artery disease lad w/< 30% stenosis migraines colonvaginal fistula vaginitis discharge condition: mental status: clear and coherent. level of consciousness: lethargic but arousable. activity status: ambulatory - independent. discharge instructions: dear mrs [**known lastname 24621**]: you came to the hospital with need for a stent placement to evaluate your response after the tracheal stent. you had a good response; however, after the stent removeal you required icu monitoring for upper airway compromise. you did well on heliox, then slowly coming off the heliox back to room air. you are given a burst of steroid and then a prednisone [**doctor last name 2949**]. you also had slight adverse reaction to succinocholine which you got during anesthesia. your reaction was fatigue. you recovered to your baseline before your discharge. please note we made the following changes: started: # prednisone taper for 5 days: 50mg on day 1, 40mg on day 2, 30mg on day 3, 20mg on day 4, 10mg on day 5. # racepinephrine 2.25 % solution for nebulization inhalation q4h (every 4 hours) as needed for 5 days # docu soft 100 mg capsule sig: one (1) capsule po twice a day. # senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. please note you need to follow up the following doctors listed below. it was a pleasure taking care of you. we wish you well on your road to recovery. followup instructions: department: hematology/oncology when: tuesday [**2174-11-8**] at 1 pm with: [**first name8 (namepattern2) **] [**name8 (md) **], md [**0-0-**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) 24**] campus: east best parking: [**hospital ward name 23**] garage department: hematology/oncology when: tuesday [**2174-11-8**] at 2:00 pm with: [**name6 (md) 1532**] [**name8 (md) 1533**], md [**0-0-**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) 24**] campus: east best parking: [**hospital ward name 23**] garage department: hematology/oncology when: tuesday [**2175-9-12**] at 1 pm with: [**first name8 (namepattern2) **] [**name8 (md) **], md [**0-0-**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) 24**] campus: east best parking: [**hospital ward name 23**] garage [**first name11 (name pattern1) 734**] [**last name (namepattern1) 735**] md, [**md number(3) 799**]",1
39,"admission date: [**2131-10-9**] discharge date: [**2131-10-15**] date of birth: [**2104-7-22**] sex: m service: medicine history of present illness: this is a 27-year-old obese mans with a history of asthma and recent episodes of pneumonia who presents with two weeks of productive cough, diaphoresis, and fatigue. the patient has asthma since childhood characterized by daily albuterol and flovent, prior hospitalization x5 (last hospitalization 14 years ago), no intubations, peak flow of 400, and dyspnea on one-block exertion, and cold weather. patient was in his usual state of health until one month prior to admission when he developed sharp right sided chest pain on inspiration and cough productive of yellow sputum. he was seen in the emergency department and found to have a right middle lobe infiltrate on chest x-ray. the patient was discharged with a diagnosis of pneumonia with asthma exacerbation, given a five day course of azithromycin. after completion of this treatment, his cough resolved and radiography demonstrated clearance of the opacity, though he reports ""feeling only slightly better."" over the next two weeks, he reported worsening productive cough with hemoptysis, intermittent fevers (unmeasured), and chills. he presented to the emergency department one week prior to admission with these symptoms and was given another five day course of azithromycin after chest x-ray was read as negative. a ppd was also planted, which was read negative in [**hospital 191**] clinic four days later. since completion of the azithromycin, patient has noticed increased dyspnea on exertion and worsening of his cough, which is productive for yellow sputum with no blood. on the morning of admission, his mother found him to have worsened cough with heavy diaphoresis and brought him into the emergency department. a multi-system review is notable for intermittent fevers, chills, fatigue, and wheezes. he is compliant with his medications, the only recent change being a decrease of gabapentin from 400 mg qid to 400 mg [**hospital1 **]. past medical history: 1. asthma. 2. hypertension. 3. gastroesophageal reflux disease. 4. bipolar disease. 5. thalassemia trait. allergies: 1. ct dye reaction being anaphylaxis. 2. the patient also notes adverse reactions to guaifenesin and cephalexin. medications: 1. albuterol 90 mcg 1-2 puffs ih [**hospital1 **]. 2. fluticasone 44 mcg two puffs ih [**hospital1 **]. 3. clonazepam 1 mg po q day. 4. gabapentin 400 mg po bid. 5. paroxetine 40 mg po q day. 6. topiramate 100 mg po bid. 7. omeprazole 20 mg po q day. 8. propanolol 80 mg po tid. family history: positive for pancreatic cancer in his father, who died when the patient was 4 years old and three uncles. liver cancer in his grandfather. family history of obesity and type 2 diabetes in maternal grandmother and maternal aunts/uncles: thalassemia traits in paternal side. social history: patient currently lives at home alone. he works as a substance abuse counselor for middle-aged woman. the patient is involved with a single male partner who has hcv, and reports condom use for all sexual encounters. he reports no recent travel outside of [**location (un) 86**], and no sick contacts. smoking: no smoking for the past two months; less than five pack year smoking history. alcohol: no current alcohol use or past history of abuse. substance: no history of recreational or iv drug use. review of systems: as above. in addition, the patient notes no chest pain, no palpitations, no paroxysmal nocturnal dyspnea/orthopnea, no nausea, vomiting, diarrhea, no dysuria/hematuria. physical examination: the patient's vital signs are temperature of 99.3, blood pressure of 130/88 supine, pulse of 104, respiratory rate of 22, and an oxygen saturation of 83% on room air which improved to 91% on 2 liters nasal cannula, and nebulizers x1. in general, the patient is a young obese ill-appearing man who seems sleepy and diaphoretic. integument: cold, dry; no rashes or ulcerations, normal pigmentation, no jaundice. heent: his head is normocephalic, atraumatic, without scalp lesions; eyes: pupils are equal, round, and reactive to light and accommodation. extraocular movements are intact. mucous membranes moist. ears - no tenderness or discharge; nose - no erythema, obstruction, discharge, no sinus tenderness; throat - no lesions or ulcerations; normal tonsils, uvula, palate, oropharynx not injected. neck: supple; thyroid normal in size without palpable masses or nodules. lymph nodes: no palpable cervical or ancillary nodes. chest: percussion difficult to assess secondary to obesity, localized wheezes right greater than left, decreased breath sounds at the bases bilaterally left greater than right, and no crackles noted on inspiration or expiration. cardiovascularly, no jugular venous distention, pmi palpable; normal s1, s2 without murmurs, rubs, or gallops. abdomen: obese, normoactive bowel sounds, soft, nontender, nondistended; liver palpable five cm down the midclavicular line. no guarding, no rebound. extremities: no clubbing, cyanosis, or edema; pedal pulses 2+ bilaterally. neurological: cns grossly intact. alert and oriented times three. studies: laboratory results are significant for a white blood cell count of 13.4 with 48 neutrophils, 14 bands, 23 lymphocytes, 9 monocytes, 4 eosinophils, and 2 basophils; a hematocrit of 41.3, and a platelet count of 594. his chemistries were notable for a sodium of 143, a potassium of 4.5, chloride of 100, a bicarb of 30, bun 9, and creatinine 0.7, alt elevated at 91, and ast at 44. an electrocardiogram demonstrated normal sinus rhythm at 100 beats per minute with normal intervals and normal axis; there were nonspecific t-wave inversions in lead v1. a chest x-ray in the emergency department showed interval development of a patchy opacity at the left lung base and a small left sided effusion. hospital course: 1. pulmonary - the patient was admitted and empirically treated for community acquired pneumonia with levofloxacin 500 mg q day and q6 nebulizers for questioned component of asthma. a sputum culture demonstrated betalactimase negative hemophilus influenza. on the second day of admission, he was found to be increasingly somnolent and less responsive. an arterial blood gas showed hypercarbia with a ph of 7.25, pco2 of 87, and a po2 of 79. the patient was then transferred to the unit secondary to decreased respiratory drive, where he was intubated later that evening after developing acute respiratory failure. he was extubated two days later after his breathing stabilized and then transferred back to our service on 4 liters of oxygen. in the unit, he was also started on high dose iv steroids and then switched to oral prednisone for taper. his examination on readmission to the service was improved with decreased fatigue, decreased diaphoresis, and a improved chest x-ray notable for decreased wheezing. over the next two days, his symptoms continued improving with continued steroid taper q6 naps and levofloxacin therapy. he was then weaned off of the oxygen and had o2 saturations of 93-95% on room air prior to discharge. during the hospitalization, he had a negative lower extremity noninvasive study that did not show any deep venous thromboses, a lung scan that showed low probability for pulmonary embolism and an echocardiogram that demonstrated normal left ventricular function with no valvular abnormalities or pericardial effusion. on discharge, he will follow up with pulmonary clinic, pulmonary function tests laboratories, and sleep laboratory as an outpatient. 2. hypertension: in the setting of acute respiratory failure and established history of asthma, inderal was discontinued after hospital day #2. his blood pressure was well controlled on lasix 40 mg po q day while in the hospital, and then he was also given diltiazem 30 mg po qid for rate control. on the last day of admission, he required potassium supplementation, [**first name5 (namepattern1) 233**] [**last name (namepattern1) 1002**] in the setting of a potassium down to 3.3. 3. endocrine: the patient was found to have a suppressed tsh in the hospital. a free t4, total t4, and t3 were ordered for followup as an outpatient. the patient also had high fasting glucose levels while in the hospital, and hba1c was obtained for followup as well. discharge condition: good. discharge placement: home. discharge diagnoses: 1. acute respiratory failure. 2. community acquired pneumonia. 3. hypertension. 4. impaired fasting glucose. 5. suppressed tsh. discharge medications: 1. albuterol inhaler. 2. flovent inhaler. 3. neurontin 400 mg po bid. 4. paxil 40 mg po q day. 5. protonix 48 mg po q day. 6. topamax 100 mg po bid. 7. lasix 40 mg po q day. 8. levofloxacin 500 mg q day. 9. prednisone 30 mg po q day taper over the next eight days. 10. diltiazem 60 mg po qid. 11. ipratropium bromide inhaler. 12. potassium chloride 40 meq po bid. as discussed above, the patient will follow up with dr. [**last name (stitle) 9006**], his primary care physician on wednesday. in addition, he will be seen for long-term evaluation and therapy in the pulmonary clinic. in addition, he will follow up in pft laboratory and sleep laboratory for further evaluation. [**first name8 (namepattern2) **] [**name8 (md) **], m.d. [**md number(1) 10885**] dictated by:[**name8 (md) 25490**] medquist36 d: [**2131-10-22**] 15:23 t: [**2131-10-25**] 06:39 job#: [**job number 25491**]",1
40,"admission date: [**2104-5-29**] discharge date: [**2104-6-2**] date of birth: [**2081-3-17**] sex: f service: obstetrics/gynecology allergies: vancomycin attending:[**first name3 (lf) 21007**] chief complaint: vulvar abscess tachycardia major surgical or invasive procedure: incision and drainage history of present illness: 23 year old female 4 months postpartum presenting with recurrent left labial abscess. the patient was first treated for a labial abscess in [**3-20**] with i/d and oral antibiotics. she did not complete the course of bactrim. three days prior to admission she noted the onset of swelling and pain over the left labia majora. she had pain with walking and sitting. no fever, chills or other systemic symptoms. she presented today for evaluation. . in the ed, vitals were 98 113/66 93 16 99% ra. she underwent i/d of the labial cyst and developed chills/rigors following the procedure. her bp dropped to 86/63 and heart rate increased to 130s. she was given 4l of fluid, but remained tachycardic and was admitted to the icu for further management. tmax 99.9. she was treated with vancomycin and ceftriaxone. she had a reaction to the morphine with lightheadedness and rash, treated with benadryl. blood and wound cultures taken after administration of antibiotics. gyn was consulted. . at arrival to the floor, she is feeling tired and but without acute complaint. she has some mild tightness across her chest with deep inspiration but denies chest pain or specific shortness of breath or wheezing. she denies scratchy or swollen throat or tongue, but does note some hoarseness to her voice. not sexually active currently, no new partners or hiv risk factors since her delivery. no leg swelling or redness. she is not breast feeding. past medical history: pmh: none psh: drainage of vulvar abscess x 2 at bedside ob: svd x 1 [**2104-2-9**] gynhx: reports nl pap, denies hx of sti. social history: single, father of baby taking care of child. no tobacco/alcohol/drugs and works part time family history: hypertension, no history of blood clots. physical exam: 98.2 102/58 125 98% ra gen: well appearing, facial plethora, no distress, speaking fluently heent: periorbital edema, perrl, op clear, mmm, no mm swelling neck: no lad car: tachycardic, hyperdynamic precordium resp: ctab--no wheeze, crackles abd: s/nt/nd/nabs no hsm ext: no le edema gyn: left labia majora site of i/d c/d/i with wick in-place-not indurated. tender to touch, tender also along inner aspect of left leg without discrete abscess. no cellulitis. pertinent results: admission labs: =============== [**2104-5-29**] 08:30pm wbc-2.0*# rbc-4.45 hgb-13.0 hct-37.1 mcv-83 mch-29.1 mchc-34.9 rdw-15.0 [**2104-5-29**] 08:30pm neuts-57 bands-1 lymphs-42 monos-0 eos-0 basos-0 atyps-0 metas-0 myelos-0 [**2104-5-29**] 08:30pm plt count-295 [**2104-5-29**] 08:30pm glucose-65* urea n-10 creat-0.8 sodium-140 potassium-4.0 chloride-106 total co2-23 anion gap-15 [**2104-5-29**] 08:43pm lactate-4.0* [**2104-5-29**] 10:30pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg [**2104-5-29**] 10:30pm urine color-straw appear-clear sp [**last name (un) 155**]-1.003 [**2104-5-29**] 10:32pm lactate-2.0 [**2104-5-29**] 6:50 pm abscess gram stain (final [**2104-5-29**]): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. 2+ (1-5 per 1000x field): gram positive cocci. in pairs. 2+ (1-5 per 1000x field): gram negative rod(s). wound culture (final [**2104-6-2**]): staphylococcus, coagulase negative. rare growth. anaerobic culture (final [**2104-6-2**]): mixed bacterial flora-culture screened for b. fragilis, c. perfringens, and c. septicum. none isolated. [**5-29**] blood cultures x 2: pending [**5-29**] urine culture: negative brief hospital course: micu course: the patient was admitted for hypotension and tachycardia s/p labial i&d. this was likely both a manifestation of bacteremia following i&d as well as allergic reaction. her hypotension resolved with ivf boluses. she had some mild facial swelling and hoarse voice following antibiotic administration. she was started on vancomycin and unasyn, but was noted that during vancomycin administration, she again had some allergic reactions with hypotension, tachycardia, and periorbital edema. vancomycin was held and instead, she was started on bactrim for mrsa coverage. epipen remained at bedside and did not need to be used. she was also started on famotidine and benadryl standing doses for probable allergic reaction. gyn course: the patient was transferred to 12r on hd#2/pod#1. she was treated with unasyn and bactrim throughout the remainder of her hospitalization. she had no further signs or symptoms suggestive of an allergic reaction. additionally, she has daily left labial packing changes for which she was pre-medicated wit percocet. she was afebrile, with a wbc count of 4.6 on her day of discharge. she was discharged home on hd#5/pod#4 in stable condition. vna was arranged for daily labial packing changes. she will remain on augmentin and bactrim for ten days. medications on admission: prenatal vitamins discharge medications: 1. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po bid (2 times a day) for 10 days. disp:*20 tablet(s)* refills:*0* 2. augmentin 500-125 mg tablet sig: one (1) tablet po twice a day for 10 days. disp:*20 tablet(s)* refills:*0* 3. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain and packing change for 7 days. disp:*20 tablet(s)* refills:*0* 4. ibuprofen 600 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 5. 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* discharge disposition: home with service facility: [**location (un) 86**] vna discharge diagnosis: vulvar abscess adverse reaction to vancomycin discharge condition: good discharge instructions: call for fever, increasing pain, swelling, or discharge at wound, nausea and vomiting, or any other questions or concerns. take all of your antibiotics. do not drive while taking narcotics. follow up with dr. [**last name (stitle) **] at the end of this week, [**last name (stitle) 2974**], [**6-6**] clinic. followup instructions: follow up with dr. [**last name (stitle) **] at [**hospital **] [**hospital **] clinic on [**last name (lf) 2974**], [**6-6**]. [**first name8 (namepattern2) 3130**] [**last name (namepattern1) 3131**] md, [**md number(3) 21009**]",1
41,"admission date: [**2146-1-2**] discharge date: [**2146-1-4**] date of birth: [**2080-12-30**] sex: m service: medicine allergies: lisinopril attending:[**doctor first name 2080**] chief complaint: tongue swelling major surgical or invasive procedure: laryngoscopy history of present illness: 65-year-old male with history of coronary artery disease, diabetes and hypertension who presenting following discharge [**1-1**] following burhole evacuation of subdural hemorrhage presenting to the [**hospital1 18**] ed with left sided tongue swelling and dyspnea which began overnight on new years. he was recently discharged from [**hospital1 18**] after a hospitalization for evacuation of subdural hematoma. new medications on discharge include: codeine, admitted [**date range (1) 32177**] for subdural hemorrhage, was stable although did have some nausea and vomiting, was not intervened upon and discharged although did not follow up in clinic. patient represented [**12-29**] with increased confusion and right facial droop and on [**12-30**] underwent a left frontal burr hole evacuation of chronic sdh and discharged [**2145-12-31**] following operation. of note, while in house, initially, patient was not taking lisinopril, however, this was restarted 12/27 per the orders, although a medicine consult on [**12-30**] asked it to be restarted. also of note, in [**12-29**], patient was given ffp/platelet transfusion although he had normal pt/inr and platelet levels. he had adverse reaction to transfusion with hives/itching and required benadryl and monitoring for airway compromise. in the ed, initial vs were: 11:29 temp: 97.6 hr: 102 bp: 183/115 rr: 20 97% ra. he was not stridorous or wheezing. he was given diphenhydramine 50mg iv, famotidine 20mg iv, and methylprednisolone 125mg iv. he was seen by ent who performed laryngosocpy and noted a swollen glossus, and no laryngeal or epiglotteal edema. a size 7 nasopharyngeal airway and endotracheal intubation was deferred. given severity of tongue sweling and concern for the possible need for intubation, he was admitted to the micu for close monitoring. vitals on transfer were p;89 bp:163/87 rr:17 sao2:97% ra. on arrival to the micu, patient is [**last name (un) 664**] and in no acute distress. past medical history: hypertension hyperlipidemia abnormal liver function tests diabetes mellitus type ii anemia chronic paranoid schizophrenia coronary artery disease - angioplasty 6 years ago in nj exertional dyspnea eye allergy necrobiosis diabeticorum r arm pain barrett's esophagus (biopsy) social history: single, has six children (4 daughters) lives alone but stays with daughter occasionally. quit tobacco 5yrs ago after 40pack yrs - alcohol: patient denies currently, but does report drinking in [**month (only) 359**] when he fell - illicits: denies family history: no history of heeridetary angioedema, daughter with diabetes. otherwise non-contributory. physical exam: admission: vitals: t: 98.2 bp:165/80 p:89 r: 18 o2:98% general: alert, oriented, no acute distress heent: sclera anicteric, mmm, tongue is enlarged inferiorly with evidence of clear fluid filled bubbles, appearing like a jellyfish. oropharynx unable to see due to tounge enlargement, eomi, perrl, surgical scar with staples over left frontal/ parietal bone. well healed wound over right occiput. neck: evidence of swelling under central mandible, supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, skin: no evidence of hives or rashes pertinent results: admission: [**2146-1-2**] 12:00pm blood wbc-10.2 rbc-4.26* hgb-11.9* hct-36.1* mcv-85 mch-27.9 mchc-32.9 rdw-13.4 plt ct-251 [**2146-1-2**] 12:00pm blood neuts-73.4* lymphs-18.6 monos-5.1 eos-2.3 baso-0.5 [**2146-1-2**] 12:00pm blood pt-11.6 ptt-27.1 inr(pt)-1.1 [**2146-1-2**] 12:00pm blood glucose-234* urean-30* creat-1.0 na-137 k-4.2 cl-99 hco3-25 angap-17 [**2146-1-2**] 12:00pm blood alt-21 ast-20 alkphos-80 totbili-0.3 [**2146-1-2**] 12:00pm blood albumin-4.4 [**2146-1-2**] 12:00pm blood c3-pnd c4-pnd [**2146-1-2**] 12:00pm blood phenyto-14.6 brief hospital course: 65-year-old male with history of coronary artery disease, diabetes and hypertension who presenting following discharge [**1-1**] following burhole evacuation of subdural hemorrhage presenting to the [**hospital1 18**] ed with left sided tongue swelling and dyspnea which began overnight on new years. # angioedema with marked inferior aspect tongue swelling likely secondary to lisinopril which patient has been taking since [**2143**] and filled in pharmacy early [**2145-12-2**]. also possible is reaction to dilantin. patient was managed with a nasal trumpet initially and no intubation. patient was admitted to the icu for airway monitoring. lfts were normal and at time of icu transfer, c4, c3 were pending. we held lisinopril and started hctz 25mg daily for htn control (patient was on hctz in the past, held for ""hypotension""). we also stopped dilantin (level was 14.6 and therapeutic) and switched over to keppra 750mg [**hospital1 **] to be continued until seen in neurosurgery clinic. we also started methylprednisolone 125mg q8h for a day and then switched to po decadron 10mg q8h to continue for a total of 6 days and no taper. we also started famotidine 20mg q12h and diphenhydramine 50mg tid in the peri-angioedema period. within 24 hours of arrival to the icu, the patient's tongue inflammation reduced considerably. patient was initially kept npo, but was then transitioned to full diet without difficulty. he was then transferred to the floor. he improved significantly with dexamethasone therapy. his daughter confirmed that she would throw out his lisinopril and dilantin at home and ensure he follows up to his pcp appointment the following day. # recent subdural hematoma with evacuation [**2145-12-29**]: no neurologic defecits at this time. as above, we held dilantin given possible sjs with dilantin (maybe appearing as angioedema in this instance) and switched to keppra 750mg [**hospital1 **] after talking with the neurosurgery team. we held dilantin and patient will continue keppra until following up with neurosurgery clinic. patient needed staples removed either by neurosurgery as an outpatient or in house between [**date range (1) 32178**]/12 and was told to schedule a follow up with them. # diabetes, type 2 uncontrolled - a1c 9.3, prior to previous admission, patient on glyburide, metformin and insulin detemir. glyburide discontinued on discharge and decrease dose to 25u at bedtime (approx [**2-4**] of home dose of 35u at bedtime) and started insulin sliding scale. in the unit, patient was given insulin sliding scale as well as glargine 20units while npo q24h. on the floor he had some sugars in the 200s, occasionally 300s due to steroids which we felt would improve after stopping steroids in 2 days. he will go to 35 units on discharge/ when eating, which is identical to his home dose. his pcp will continue to follow his blood sugars. # hypertension - patient hypertensive at admission 183/115 and was on lisinopril since [**2143**] (confirmed by pharmacy). we started hctz as above 25mg qd with permissive hypertension to the 150s while the patient on steroids. his pcp can follow up his blood pressures and a chem 7. # schizophrenia/ psych/ neuro: we continued perphenazine 12mg po qhs and benztropine 2mg [**hospital1 **]. held alprazolam 2mg po qhs, given diphenhyrdamine. medications on admission: 1. docusate sodium 100 mg capsule [**hospital1 **] 2. alprazolam 2 mg po qhs 3. betamethasone dipropionate 0.05 % cream appl topical [**hospital1 **] 4. benztropine 2 mg [**hospital1 **] 5. perphenazine 12 mg tablet po qhs 6. lisinopril 40 mg tablet po daily 7. phenytoin 125 mg/5 ml suspension po tid 8. simvastatin 40 mg tablet daily 9. tylenol-codeine #3 300-30 mg 1 tablet po q6 hours prn pain. 10. combivent 18-103 mcg/actuation aerosol sig: two (2) puff inhalation four times a day as needed for shortness of breath or wheezing. discharge medications: 1. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 2. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po tid (3 times a day) for 3 days. disp:*9 capsule(s)* refills:*0* 3. perphenazine 8 mg tablet sig: 1.5 tablets po qhs (once a day (at bedtime)). 4. benztropine 1 mg tablet sig: two (2) tablet po bid (2 times a day). 5. dexamethasone 4 mg tablet sig: 2.5 tablets po q8h (every 8 hours) for 2 days. disp:*18 tablet(s)* refills:*0* 6. levetiracetam 500 mg tablet sig: 1.5 tablets po bid (2 times a day). disp:*90 tablet(s)* refills:*2* 7. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. multivitamin tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 10. insulin glargine 100 unit/ml solution sig: thirty five (35) units subcutaneous at bedtime. 11. alprazolam 2 mg tablet sig: one (1) tablet po at bedtime. 12. combivent 18-103 mcg/actuation aerosol sig: two (2) 2 puffs inhalation every six (6) hours as needed for shortness of breath or wheezing. 13. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. 14. simvastatin 40 mg tablet sig: one (1) tablet po once a day. discharge disposition: home with service facility: [**location (un) 86**] vna discharge diagnosis: angioedema anemia diabetes mellitus type ii discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure to take care of you here at [**hospital1 18**]. you were admitted for tongue swelling called ""angioedema"". this was thought to be due to lisinopril, which can happen any time while on this medication. a much less likely possibility is a reaction from your new seizure medication dilantin, therefore, to be safe, we also changed you to a different seizure medication called keppra. if you develop worsening swelling or difficulty breathing, please go to the emergency room immediately. also, we noted your blood counts are low, you will need an endoscopy for your barrett's esophagus screening and a repeat colonscopy given your polyp. we have made the following changes to your medications: stop lisinopril (your daughter will throw away all your pills) stop dilantin (your daughter will throw away all your pills) for seizure prevention due to your recent head injury: start keppra 750mg by mouth twice daily for your angioedema: start dexamethasone 12mg by mouth every 8 hours for two more days (last dose [**2146-1-6**]) start benadryl 25mg by mouth three times daily for 2 more days for your alcohol use: start multivitamin, folate, and thiamine followup instructions: please set up an appointment with neurosurgery within 2 weeks: ([**telephone/fax (1) 88**]. department: [**hospital1 7975**] internal medicine when: wednesday [**2146-1-5**] at 11:15 am with: [**first name11 (name pattern1) **] [**last name (namepattern4) 10134**], md [**telephone/fax (1) 7976**] building: [**hospital1 7977**] ([**location (un) 686**], ma) [**location (un) **] campus: off campus best parking: free parking on site department: [**hospital 7975**] [**hospital **] health center when: monday [**2146-2-7**] at 10:00 am with: [**doctor first name 674**] brow [**telephone/fax (1) 7976**] building: [**hospital1 7977**] ([**location (un) 686**], ma) [**location (un) **] campus: off campus best parking: free parking on site department: [**hospital 7975**] [**hospital **] health center when: tuesday [**2146-2-22**] at 10:00 am with: [**first name8 (namepattern2) **] [**last name (namepattern1) 22387**], md [**telephone/fax (1) 7976**] building: [**hospital1 7977**] ([**location (un) 686**], ma) [**location (un) **] campus: off campus best parking: free parking on site completed by:[**2146-1-5**]",1
42,"admission date: [**2113-1-14**] discharge date: [**2113-1-24**] service: medicine allergies: zestril / lipitor attending:[**first name3 (lf) 6114**] chief complaint: fever, hypotension. transfer from [**hospital3 7571**]hospital. major surgical or invasive procedure: central venous line placement (femoral) picc line insertion transesophageal echocardiogram history of present illness: 89 year-old male with cad s/p cabg, a fib on coumadin, cryptogenic cirrhosis, dm type 2, and myelodysplastic syndrome with pancytopenia, with recent history of enterococcus uti and bacteremia ([**2112-12-18**]) at osh complicated by presumed subacute endocarditis ([**2113-1-4**], tee negative at osh), recently discharged on [**1-12**] from osh to rehabilitation center with picc in right arm with plan to complete a total of 4 weeks of amp and gent. on [**1-13**] at nh, patient developed recurrent fever to 100.6, +sob with saturation 92% ra. he was given vancomycin 1 gm iv x1 and transferred to [**location (un) **] ed where bp 88/57. a dopamine infusion was initiated. a cxr was consistent with chf, with bnp 1090 and patient was given lasix 80 mg iv x1. he was subsequently transferred to the [**hospital1 18**] ed for further care, where bp initially 70/40 on 5 mcg/kg/min of dopamine. in the ed, blood cultures were sent. a bedside echo was performed and showed no pericardial effusion. on ros, +sob, + cough productive of white sputum. + chills at osh. the patient was admitted to the micu. past medical history: 1. cad s/p cabg in [**2098**] 2. dm type 2 on prandin 3. chronic atrial fibrillation on coumadin 4. myelodysplastic syndrome with pancytopenia (not transfusion dependent) 5. cryptogenic cirrhosis diagnosed by biopsy 6. chronic renal insufficiency with [**year (4 digits) 5348**] creatinine 2.0 7. hyperlipidemia 8. h/o chf, query diastolic dysfunction (normal ef) 9. enteroccus uti and bacteremia ([**2112-12-18**]), complicated by presumed enterococcus endocarditis ([**2113-1-4**]). social history: he lives in [**location **] (ma) with his wife. remote ex-smoker, with 10 pack-year smoking history. he quit in [**2070**], no etoh consumption. family history: non-contributory. physical exam: per admission note on [**2112-1-14**]. vs: 98.7, 117/85, hr 87, r 18, 96% 2l gen: nad, very pleasant heent: eomi, o/p clear neck: supple, jvp at 8cm chest: scattered rhonchi, wheezes, crackles at bases bilaterally cv: rrr, 3/6 sem that radiates to clavicle and carotid abd: soft, distended, nt, + bs ext: no edema, 2 piv neuro: a and o x 3, moves all 4 extremities pertinent results: relevant laboratory data on admission: cbc: [**2113-1-14**] wbc-2.8* rbc-2.61* hgb-9.7* hct-28.7* mcv-110* rdw-15.5 plt -102 (neuts-83* bands-2 lymphs-5* monos-9 eos-0 basos-1 atyps-0 metas-0) coagulation profile: pt-17.4* ptt-37.8* inr(pt)-1.9 chemistry: glucose-119* urea n-37* creat-1.8* sodium-138 potassium-3.4 chloride-100 total co2-33* anion gap-8 calcium-8.3* phosphate-3.4 magnesium-2.1 alt-34 ast-61* ck(cpk)-303* alkphos-148* amylase-128* totbili-2.1* lactate-2.2* random cortisol 17.5 cardiac enzymes: [**2113-1-14**] 02:10am ck-mb-4 c tropnt-0.09* [**2113-1-14**] 03:28pm ck-mb-6 ctropnt-0.08* [**2113-1-15**] 04:23am ck-mb-5 ctropnt-0.07* [**2113-1-16**] 06:11am ctropnt-0.06* urinalysis: [**2113-1-14**] 02:10am blood-mod nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg urine rbc-0-2 wbc-0 bacteria-rare yeast-none epi-1 ekg: atrial fibrillation. probable old septal infarct. inferior/lateral t changes are nonspecific. repolarization changes may be partly due to rhythm. since previous tracing, no significant change. cxr: the cardiac contour is somewhat rounded, but normal in size. mediastinal contours are normal. there is slight blunting of both costophrenic angles with minor atelectatic changes seen at the lung bases. there is no focal consolidation. pulmonary vasculature appears slightly prominent, but there is no chf. the patient is post cabg with median sternotomy wires and clips seen in the mediastinum. the osseous structures are unremarkable. impression: slight blunting of the costophrenic angles. no definite chf. no pneumonia. relevant data in hospital: tee [**2113-1-16**]: 1. 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. 2. left ventricular wall thicknesses and cavity size are normal. left ventricular function is normal (lvef 60-65%). 3. right ventricular chamber size and free wall motion are normal. 4.there are simple atheroma in the ascending aorta, in the aortic arch, and in the descending thoracic aorta. 5.the aortic valve leaflets are severely thickened/deformed. no masses or mobile vegetations are seen on the aortic valve, however cannot exclude a sessile vegetation (the valve leaflets are severely calcified). no aortic valve abscess is seen. there is probably moderate aortic valve stenosis (recommend transthoracic echo for complete evaluation of the aortic stenosis if clinically indicated). trace aortic regurgitation is seen. 6. the mitral valve leaflets are moderately thickened. no mass or vegetation is seen on the mitral valve. moderate to severe (3+) mitral regurgitation is seen. 7.the tricuspid valve leaflets are mildly thickened. moderate [2+] tricuspid regurgitation is seen. 8.there is no pericardial effusion. no prior strudy available for comparison. [**2113-1-17**]: limited abdomen ultrasound: there is a tiny amount of fluid adjacent to the liver. there are no loculated fluid collections. brief hospital course: 89 year-old male with mmp including cad, atrial fibrillation on coumadin, and recent admission to osh with enterococcus fecalis uti and bacteremia, complicated by presumed enteroccus endocarditis (negative tee but recurrent positive blood cultures and ongoing fever), treated with ampicillin iv (1 gm iv q 6 hours) and gentamicin iv (started on [**2113-1-5**]), now admitted with fever, hypotension and respiratory symptoms. his hospital course will be reviewed by problems. 1) hypotension/fever: given the hypotension in the setting of recurrent fever and recent enterococcal bacteremia, the most likely etiology was felt to be septic shock +/- cardiogenic component. a bedside echo on admission showed relatively preserved ef, no pleural effusion. it was unclear whether his fever/hypotension were related to persistent enterococcal infection or a new nosocomial infection. cxr was without pna and u/a clear. cultures sent. given concern over potential line infection, picc line was d/c'd on admission. the antibiotic regimen was changed to vancomycin iv and gentamycin iv for rx of enterococcus +/ line infection. the patient was quickly weaned off dopamine in the icu, and was transferred to the floor on [**2113-1-15**]. all cultures at [**hospital1 18**] were unremarkable. however, mr. [**known lastname **] continued to spike fever up to 102.3 on vancomycin and gentamicin. a repeat tee was performed on [**2113-1-16**], which revealed normal lvef 60-65%, and no vegetation although a sessile vegetation could not be ruled out given severe calcification of aortic valve. probable moderate as, trace ar, moderate to severe mr (mild mr in [**2111**]), moderate tr. an abdominal u/s was also performed, which revealed a small amount of ascites and no fluid collection. id was consulted. given his respiratory symptoms, levofloxacin 500 mg po qd was added to cover for pulmonary organisms. a nasal wash was also sent to rule out influenza, which came back positive for influenza a. in retrospect, his acute presentation was felt likely secondary to influenza. given the duration of his symptoms and clinical improvement, decision was taken not to treat. he was kept on droplet precautions in hospital (d/c'd on [**2113-1-24**]). levofloxacin d/c'd on [**2113-1-20**]. respiratory symptoms resolved at the time of discharge. intermittent wheezing in hospital, kept on albuterol and ipratropium nebs prn. of note, sensitivities were repeated on the osh isolate and ampicillin sensitivity was confirmed, mic <=2. antibiotics were changed back to ampicillin 1 gm iv q 6 hours, and gentamicin 80 mg iv q 48 hours (dose adjusted according to levels and creatinine) on [**2113-1-20**]. ampicillin increased to 2 gm iv q 8 hours on [**2113-1-23**] after discussion with id team. plan is to complete 6 weeks of therapy with ampicillin and gentamicin (last doses on [**2113-2-16**]). picc line in place. will need gentamicin levels every 4th day (goal peak=3, trough=1). hold gentamicin if creatinine >2.5. 2) chf: lasix and spironolactone were held on admission given hypotension, restarted on [**2113-1-15**]. cxrs in hospital revealed progressive fluid overload, and lasix dose was titrated up to maintain negative fluid balance. per patient's wife, out-patient lasix dose is 160 mg po qam and 120 mg po qpm. on lasix 80 mg po bid at discharge, with goal to titrate to even to negative fluid balance as an out-patient. [**date range **] weight 140lbs. low threshold to increase lasix if increasing edema on exam, or >=3lbs weight gain as creatinine tolerates. 3) cad: troponin 0.09 (peak) on admission, felt likely troponin leak in the setting of infection and renal failure. ekg without acute ischemic changes. in hospital, he was continued on metoprolol and asa. history of adverse reaction to ace. also continued on zetia for hyperlipidemia. 4) atrial fibrillation: metoprolol initially held in the setting of hypotension, restarted as bp tolerated. good rate control on 25 mg po bid. patient also continued on coumadin, with goal inr [**2-16**]. coumadin dose decreased to 1 mg po qhs given elevated inr in hospital (out-patient dose 2mg po qhs). inr 2.0 will need close monitoring at rehab. 5) diabetes mellitus type 2: poor glycemic control in hospital. prandin was held, and he was started on glargine at night, titrated up to 9 units qhs, along with riss, with plan to manage on glargine as an out-patient. patient will need teaching at rehab center. would not restart prandin. 6) mds with pancytopenia: per patient's pcp, [**name10 (nameis) 5348**] hct around 32-33. while in hospital, patient transfused a total of 3 units of prbcs to maintain hct >30 given known cad. platelets stable in low 100k, and wbc around [**name10 (nameis) 5348**] of 3. 7) chronic renal insufficiency: creatinine around [**name10 (nameis) 5348**] of 2 in hospital, slightly higher on [**2113-1-23**] at 2.2. gentamicin levels monitored carefully in hospital given risk of nephrotoxicity and ototoxicity. patient will need gentamicin levels q 4 days, with goal peak=3 and trough=1. plan to d/c gentamicin if creatinine >=2.5. 8) cryptogenic cirrhosis: patient continued on spironolactone and lactulose in hospital. of note, patient noted to have mild elevation of alkaline phosphatase, total bilirubin and ggt in hospital, also elevated at osh. abdominal u/s at osh negative for cbd dilatation, no gb wall thickening, no pericholecystic fluid. no acute issues in hospital. 9) prophylaxis: on coumadin, protonix (history of pud) and bowel regimen in hospital. code: dnr/dni per discussion with patient and family. medications on admission: meds on transfer from micu: coumadin 2 mg po qd lasix 80 mg iv qd spironolactone 25 mg po qd gentamicin 120 mg iv qd (d2) lacutlose 30 mg po tid vancomycin 1 g iv qd (d2) dulcolax 10 mg po/pr prn senna prn atrovent neb q 6h albuterol neb q 6h prn asa 325 mg po qd zetia 10 mg po qd colace 100 mg po bid folate 1 mg po qd mvi 1 po qd protonix 40 mg po qd celexa 10 mg po qd riss tylenol prn discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. citalopram hydrobromide 20 mg tablet sig: 0.5 tablet po daily (daily). 3. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. multivitamin capsule sig: one (1) cap po daily (daily). 5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). 8. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 9. albuterol sulfate 0.083 % solution sig: one (1) neb inhalation q6hrs: prn as needed for shortness of breath or wheezing. 10. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6hrs: prn as needed for shortness of breath or wheezing. 11. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 12. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 13. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 14. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 15. lactulose 10 g/15 ml syrup sig: thirty (30) ml po tid (3 times a day): titrate to 2 bm per day. 16. warfarin sodium 1 mg tablet sig: one (1) tablet po hs (at bedtime): please monitor daily inr until stable. 17. furosemide 80 mg tablet sig: one (1) tablet po bid (2 times a day): please monitor daily weight. . 18. gentamicin in normal saline 80 mg/50 ml piggyback sig: eighty (80) mg intravenous q48h (every 48 hours): please hold dose on [**2113-1-24**].check daily creatinine; if stable or decreasing, then resume dose q48 hours on [**2113-1-26**]. please check gentamicin levels every 4th day (every 2 doses). last doses on [**2113-2-16**]. 19. ampicillin sodium 2 g recon soln sig: one (1) recon soln injection q8h (every 8 hours): please give 2 gm iv q8 hours. last doses on [**2113-2-16**]. 20. insulin glargine 100 unit/ml solution sig: nine (9) units subcutaneous at bedtime. 21. regular insulin sliding scale [**hospital1 **] discharge disposition: extended care facility: [**hospital6 25759**] & rehab center - [**location (un) **] discharge diagnosis: primary diagnoses: influenza a probable enterococcus endocarditis coronary artery disease atrial fibrillation congestive heart failure diabetes mellitus type 2 myelodysplastic syndrome chronic renal insufficiency secondary diagnoses: cryptogenic cirrhosis hyperlipidemia discharge condition: patient discharged to rehab facility in stable condition. discharge instructions: patient will need follow-up with pcp (dr. [**last name (stitle) 29032**] after d/c from rehab facility. please arrange follow-up appointment prior to d/c. followup instructions: please arrange follow-up with dr. [**last name (stitle) 29032**] (pcp) prior to d/c from rehab. completed by:[**2113-1-24**]",1
43,"admission date: [**2124-3-31**] discharge date: [**2124-4-6**] date of birth: [**2044-4-18**] sex: m service: medicine allergies: calcium / penicillins / cephalosporins attending:[**first name3 (lf) 1943**] chief complaint: fever major surgical or invasive procedure: none history of present illness: 79 year old male with a history of hypertension, type ii dm, systolic heart failure (with ef of 45%) and cva ([**2101**],[**2121**]) with residual right hemiplegia and dysarthria who is presenting with fever from his nursing home. he developed a fever to 104. he was brought to the ed for this reason. in the ed, he was tachycardic to the 140s, however this resolved after fluid resuscitation. a foley was placed and frank pus was noted. he was also noted to be in acute renal failure with a creatinine of 2.0 compared to a baseline of 0.7. chest x-ray was unremarkable. blood pressures were initially in the 90s systolic but improved with fluid administration. he was started on broad spectrum antibiotics (vancomycin, meropenem and flagyl) given the frank pus and history of clostridium difficile on prior hospitalizations. his vitals at time of transfer were: temp 98.3, pulse of 97, respirations of 28, bp of 101/64, and o2 sat of 96% on ra. he has a history of hypertension, type ii dm, systolic heart failure (with ef of 45%) and cva ([**2101**],[**2121**]) with residual right hemiplegia and dysarthria. he had a prior hospitalization in [**month (only) 958**] after presenting with somnolence and found to have a left sided pneumonia - he was started on levaquin and required transfer to micu where ; also in [**month (only) 956**] of this year for a clogged g-tube and ir replacement and in [**month (only) 404**] for hypoxic respiratory failure in setting of h. influenza pneumonia complicated by an upper gi bleed from g-tube site and clostridium difficile infection. at time of transfer, his vitals were normalized - his temperature was 98, his heart rate was 90, sbp was 90/70, rr 12, 98% on ra. past medical history: 1. multiple strokes: 1)old remote left frontal stroke in [**2101**] that per nh notes purportedly left him with r-hemi and dysarthria (per son, able to think of words he wants to say and makes grammatically intact sentences, but is often unintelligible) 2. dm2 3. htn 4. systolic heart failure with ef of 45% social history: lives at rehab. remote history of alcohol and smoking cigarettes (quit 1 year ago.) family history: unable to obtain as patient is nonverbal and not documented in omr. physical exam: on admission: vs: temp 98, rr 12, o2 sat 98%, bp 90/70, hr 90 gen: chinese male, in no apparent distress neuro: nonverbal, tracks to movement, grimacing and moans intermittently, intact reflexes cardiac: nl s1/s2 rrr no murmurs appreciable, no appreciable jvd resp: lungs clear bilaterally abd: soft, nontender and nondistended with normoactive bowel sounds ext: no edema noted discharge tmc 98.6 127/57, 85-104, 20 99ra gen: ill appearing male, non-verbal, does not appear acutely distressed. patient can track with eyes. non-verbal despite [**last name (un) **]-interpreter (baseline) cardiac: s1s2, rrr, tachycardic, no jvd, no m/r/g resp: cta b/l, no w/r/r, but not cooperative with exam abd: soft, nd, nt, +bs ext: 1+ pedeal edema. trace + ue edema, 2+ peripheral pulses neuro: nonverbal, tracks to movement, grimacing and moans intermittently, will wave tremulously if engagaged. can make occasionally make purposeful movements and. aphasic. pertinent results: 1) admission labs: [**2124-3-31**] 12:16pm blood wbc-15.6*# rbc-3.83* hgb-12.4* hct-39.2* mcv-102* mch-32.4* mchc-31.7 rdw-13.8 plt ct-389 [**2124-3-31**] 12:16pm blood neuts-85.7* lymphs-10.0* monos-3.2 eos-0.8 baso-0.3 [**2124-3-31**] 01:20pm blood pt-12.3 ptt-28.3 inr(pt)-1.1 [**2124-3-31**] 12:16pm blood glucose-339* urean-75* creat-2.0*# na-144 k-4.9 cl-103 hco3-27 angap-19 [**2124-4-1**] 04:16am blood glucose-128* urean-51* creat-1.3* na-152* k-3.9 cl-117* hco3-29 angap-10 [**2124-3-31**] 12:16pm blood calcium-8.4 phos-3.5 mg-2.8* micro: [**2124-3-31**] 12:30pm urine color-yellow appear-cloudy sp [**last name (un) **]-1.017 [**2124-3-31**] 12:30pm urine blood-sm nitrite-neg protein-100 glucose-150 ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-lg [**2124-3-31**] 12:30pm urine rbc-15* wbc->182* bacteri-many yeast-none epi-0 transe-7 [**2124-3-31**] 12:30pm urine casthy-37* [**2124-3-31**] 12:30pm urine wbc clm-many blood cultures negative. urine culture (final [**2124-4-4**]): this is a corrected report [**2124-4-2**], 11:55am. reported to and read back by dr. [**last name (stitle) **] [**numeric identifier 30972**], [**2124-4-2**], 11:55am. enterococcus sp.. 10,000-100,000 organisms/ml.. previously reported as <10,000 organisms/ml on [**2124-4-1**]. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ 8 s linezolid------------- 2 s nitrofurantoin-------- 128 r tetracycline---------- =>16 r vancomycin------------ =>32 r [**2124-3-31**] 9:16 pm mrsa screen source: nasal swab. mrsa screen (final [**2124-4-2**]): positive for methicillin resistant staph aureus. cxr [**2124-3-31**] impression: no acute cardiopulmonary process. labs upon discharge: [**2124-4-6**] 06:15am blood wbc-8.9 rbc-3.02* hgb-9.7* hct-31.1* mcv-103* mch-32.1* mchc-31.1 rdw-14.5 plt ct-353 [**2124-4-5**] 05:55am blood wbc-9.1 rbc-3.12* hgb-10.0* hct-32.4* mcv-104* mch-31.9 mchc-30.8* rdw-14.7 plt ct-319 [**2124-4-6**] 06:15am blood glucose-206* urean-17 creat-0.6 na-138 k-4.4 cl-108 hco3-24 angap-10 [**2124-4-1**] 04:16am blood alt-11 ast-14 ld(ldh)-130 alkphos-67 totbili-0.3 [**2124-4-6**] 06:15am blood calcium-8.0* phos-2.8 mg-2.1 pending results: none brief hospital course: 79 year old male with a history of hypertension, type ii dm, systolic heart failure (with ef of 45%) and cva ([**2101**],[**2121**]) with severe residual right hemiplegia and dysarthria who presented from his skilled nursing facility with vre urosepsis. 1. vre urosepsis 2. acute kidney injury 3. hypotension 4. hypernatremia 5. decubitus ulcers chronic problems: 1. type 2 diabetes. 2. s/p cva # vre urosepsis: mr [**known lastname **] presented from rehab with high fever to 104, leukocytosis, tachycardia, tachypnea, with an indwelling foley catheter. his foley catheter was removed and it was grossly purulent. he was initially started on vancomycin for the possibility of enterococcus, along with meropenem for gram negatives (he has a penicillin and cephalosporin allergy). he continued to have low grade fevers and leukocytosis on the vanc/meropenem combination. his urine cultures were finalized on [**2124-3-31**] and were sensitive to ampicillin and linezolid. he has a reported allergic history to penicillin. however, on review of his medical records, he has received unasyn for 3 days in the past as well as augmentin for 3 days in the past without any mention of adverse reaction. on the ampicillin, he has remained afebrile for 48 hours and he is without leukocytosis. given that he has a complicated, catheter related urinary tract infection, we are treating with ampicillin (500mg q6h via gtube) for a two week course, to end on [**2124-4-20**]. #acute kindey injury: the patient was admitted with a serum cr of 2. this was most likley in the setting of dehydration, hypovolemia, and urosepsis. he was given 2l iv fluids and his hypotension as well as his serum creatinine improved to 1.3. over the duration of his hospital course as the patient was no longer hypotensive or intravascularly depleted, his renal function returned to his baseline of 0.8. # hypotension: given his initial presentation of hypotension. the patients metoprolol and hctz-triameterene were held. he has not been hypertensive during this admission, therefore we remained to hold these medications during inpatient hospitalization. #hypernatremia: when the patient presented to the floor he was hypernatremia to 150. the patient is strict npo after his stroke and has limited access to free water. he was given free water flushes as well as d5w. his serum sodium stayed at 150 and then decreased to the low 130's. his tubefeeds were continued with at 75cc/hr without free water flushes which returned him to normonatremia. we suggest rechecking his chem 7 on [**2124-4-8**] and then every 72 hours. his free water flushes might need to be increased pending his serum sodium. #wound care: patient has stage two decubitus ulcers. wound care recommendations are included within the page one of the discharge paperwork. # s/p cva: - patient is s/p two cva's. he has severe residual deficits from his cvas. he can track with his eye movements and is aware of people in the room. he can recognize familiar faces and occasionally say one word. according to his son, he has not spoken a complete sentence in a ""very long time."" # type ii dm. glyburide was held and he was maintained on insulin sliding scale. transitional issues: 1. continue ampicillin for enterococcal uti for 14 days (last day of antibiotics [**2124-4-20**]) 2. outpatient lab work please check chem 7 and cbc on [**2124-4-8**] and then q72h. please notify [**name8 (md) **] md of results. 599.0 3. please alter the amount of free water patient receives in flushes if patient becomes hypernatremic. 4. please follow up wound care recommendations as listed in paperwork for decubitus ulcers. 5. please restart metoprolol 50 mg tid and hctz-triamterene 37.5/25 mg daily as blood pressure tolerates medications on admission: mva pg daily omeprazole 20 mg pg qdaily plavix 75 mg pg qdaily triamterene-hctz 37.5/25 mg pg qdaily pravastatin 20 mg pg qdaily ferrous sulfate liquid 300 mg pg [**hospital1 **] glyburide 3 mg pg [**hospital1 **] vitamin c 500 mg pg [**hospital1 **] albuterol prn metprolol 50 mg pg tid tamsulosin 0.4 mg pg daily levaquin 500 mg pg daily x 10 days (started [**2124-2-10**]) day 4 today citalopram 20 mg pg daily glucerna 1.0 cal @ 75 cc/hr pg humalog sliding scale (received 6-12 units every other day) discharge medications: 1. clopidogrel 75 mg tablet [**year (4 digits) **]: one (1) tablet po daily (daily). 2. pravastatin 20 mg tablet [**year (4 digits) **]: one (1) tablet po daily (daily). 3. tamsulosin 0.4 mg capsule, ext release 24 hr [**year (4 digits) **]: one (1) capsule, ext release 24 hr po hs (at bedtime). 4. citalopram 20 mg tablet [**year (4 digits) **]: one (1) tablet po daily (daily). 5. heparin (porcine) 5,000 unit/ml solution [**year (4 digits) **]: one (1) injection tid (3 times a day). 6. lansoprazole 30 mg tablet,rapid dissolve, dr [**last name (stitle) **]: one (1) tablet,rapid dissolve, dr [**last name (stitle) **] daily (daily). 7. ampicillin 125 mg/5 ml suspension for reconstitution [**last name (stitle) **]: five hundred (500) mg po q6h (every 6 hours) for 14 days: last day [**4-8**]. 8. omeprazole 2 mg/ml suspension for reconstitution [**month/day/year **]: twenty (20) mg po once a day. 9. outpatient lab work please check chem 7 and cbc on [**2124-4-8**] and then q72h. please notify [**name8 (md) **] md of results. 599.0 10. insulin aspart 100 unit/ml solution [**name8 (md) **]: as dir units subcutaneous please see sliding scale: per sliding scale . discharge disposition: extended care facility: [**hospital **] healthcare center - [**location (un) **] discharge diagnosis: active: 1. vre urosepsis 2. urinary tract infection, complicated, cathetered related. 3. stage 2 decubitus ulcers 4. acute kidney injury 5. hypernatremia chronic: 1. cerebrovascular accident 2. type 2 diabetes 3. hypertension discharge condition: mental status: confused - always. level of consciousness: lethargic but arousable. activity status: bedbound. discharge instructions: dear mr. [**known lastname **], you were admitted for a very bad infection in your bladder which was most likely caused by an indwelling catheter. as a result of this infection, you became extremely ill and required monitoring overnight in the icu. initially you were on very broad spectrum antibiotics but once the urine cultures came back we put you on a more specific antibiotic focused on treating your complicated urinary tract infection. we have started you on the following antibiotic. 1. ampicillin 500mg every six hours through your feeding tube for 2 weeks. your blood pressure was initially low so we held some of the following blood pressure medications: 1. holding triameterene-hctz 2. holding metoprolol since you had acute kidney injury we held your glyburide. this has now resolved and it is between you and your outpatient providers if you would like this medication restarted. 1. holding glyburide. followup instructions: when you are discharged from rehab please call [**last name (lf) **],[**first name3 (lf) **] [**telephone/fax (1) 10349**] for a follow up appointment.",0
44,"admission date: [**2193-6-16**] discharge date: [**2193-7-2**] date of birth: [**2123-3-6**] sex: f service: medicine allergies: sulfonamides / levaquin / lasix / ranitidine attending:[**first name3 (lf) 5123**] chief complaint: hypoxia major surgical or invasive procedure: none history of present illness: 70f with cad s/p cabg, s/p hepatorenal bypass for ras presented with fevers and hypoglycemia. the pt reported she began experiencing uti like symptoms, specfically dysuria, early this week. on thursday she went to her pcp where she was prescribed ciprofloxacin. pt states she took doses on thursday night and twice on friday. she discontinued the medication on saturday [**12-24**] to nausea. pt reports that on saturday pm, she noted fevers to 102f. upon waking on the morning of admission, she felt shaky. her daughter, who is a nurse, took her fs which was found to be 24. the pt subsequently was brought to the ed. the pt denies current dysuria or back pain. she denies any cough. she notes mild gerd like symptoms. no chest pain. upon arrival to the ed 99.5 117/56 79 16 93%ra. while in the ed the pt spiked to 100.5f and at one point had bp of 89/41. cr 2.6 from 1.6. no cvat. lactate initiately 2.3 which improved to 1 following 3l of ns. ces negative x1. cxr unremarkable. ct abd/pelvis without signs of pyelonephritis. the pt received 1 gm of ceftriaxone. the pt also received gi cocktail for mild gerd like symptoms. 1 piv placed, 18g. vitals prior to transfer to the floor were t100.5 hr 76 bp 135/53 rr 19 sats 95% on ra. ekg wnl. past medical history: # cad s/p cabg x 4 ([**2184**]): left internal mammary artery to proximal lad, reversed autogenous saphenous vein to second circumflex descending coronary arteries # ckd # ras s/p hepatorenal bypass with [**doctor last name 4726**]-tex graft ([**2183**]) # pad s/p aorta-bifemoral bypass graft ([**2170**]) s/p redo in [**2182**] # htn # gerd # depression # gout social history: no current tobacco. long-time former smoker. no etoh. lives with daugher. family history: non-contributory physical exam: vitals - t: 100.6 hr 80 bp 133/54 rr 33 sat 95/50% face mask general: pleasant, well appearing caucasian femail in nad heent: mmm, normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla/eomi.op clear. neck: supple, no lad, no thyromegaly. cardiac: distant heart sounds. regular rhythm, normal rate. normal s1, s2. no murmurs, rubs or [**last name (un) 549**]. jvp 12 cm lungs: ctab, good air movement biaterally. abdomen: nabs. soft, nt, nd. no hsm extremities: 1+ edema to ankles, 2+ dorsalis pedis/ posterior tibial pulses. skin: no rashes/lesions, ecchymoses. neuro: a&ox3. appropriate. cn 2-12 grossly intact. pertinent results: labs on admission: [**2193-6-16**] wbc-5.4 rbc-3.78* hgb-11.8* hct-34.2* mcv-90 rdw-13.1 plt ct-94*# neuts-76.8* lymphs-8.6* monos-4.4 eos-9.2* baso-0.9 pt-13.1 ptt-27.2 inr(pt)-1.1 glucose-139* urean-44* creat-2.6*# na-131* k-4.2 cl-101 hco3-16* angap-18 calcium-8.7 phos-3.0 mg-1.5* lactate-1.0 alt-10 ast-16 ck(cpk)-35 alkphos-98 totbili-0.3 lipase-32 labs on discharge [**2193-7-2**]: wbc 5.2, hgb 8.0, hct 25.0, mcv 93, plt 226k 139 105 41 agap=14 ------------< 100 4.3 24 1.9 ca: 8.5 mg: 2.0 p: 4.3 other labs cardiac enzymes on [**7-31**], [**6-18**], [**6-19**], and [**6-20**] were all negative bnp on [**6-18**]: 16,773 bnp on [**7-1**]: 4,214 [**2193-6-19**] vitb12-288, mma 282 [**2193-6-17**] hapto-189, fibrinogen 303 [**2193-6-18**] caltibc-207* ferritn-145 trf-159* [**2193-6-18**] crp-35.2*, esr-8 [**2193-6-20**] spep negative, upep negative micro: all cultures were negative, including: multiple blood cultures multiple urine cultures lyme serology legionella urinary ag cmv (ab + viral load) ebv (igg positive, igm negative) influenza cdiff anaplasma igg/igm aspergillus/galactomannan b-glucan babesia parvovirus (igg + at 5.03, igm negative) strongyloides other studies: [**2193-6-16**] ekg: sinus rhythm. the p-r interval is prolonged. left axis deviation. non-specific intraventricular conduction delay. there is a late transition with tiny r waves in the anterior leads consistent with probable prior anterior myocardial infarction. non-specific st-t wave changes which may be related to left ventricular hypertrophy, although ischemia or myocardial infarction cannot be excluded. compared to the previous tracing the p-r interval and the qrs duration are longer. [**2193-6-16**] cxr: the patient is status post median sternotomy and cabg. the cardiac silhouette is stable and remains mildly enlarged. the aorta is slightly tortuous with calcifications again demonstrated. pulmonary vascularity is within normal limits. lungs are clear. there is no pleural effusion or pneumothorax. the osseous structures are unremarkable. several clips in the right upper quadrant and upper abdomen are redemonstrated. [**2193-6-16**] ct abd/pelvis w/o contrast: 1. no acute findings to explain patient's symptoms. 2. left renal atrophy with severe atrophy of the posterior aspect of the right kidney, stable. 3. status post aortobifemoral bypass graft, incompletely assessed on this non- iv contrast-enhanced study. [**2193-6-19**] ct chest w/o contrast: 1. several foci of peribronchiolar consolidation, mostly dependent in location. the lower lobe findings are new compared to the abdomen/pelvic ct from three days ago. rapid onset and distribution favor aspiration pneumonia as an etiology. 2. mild pulmonary edema. 3. enlarged mediastinal lymph nodes, most likely reactive. 4. mild lower lobe bronchiectasis. 4. 5-mm perifissural nodule versus small amount of loculated fluid mimicking a nodule at the right lung base. attention to this area on a follow up ct in 6 months may be considered, especially if there are risk factors for lung neoplasm. [**2193-6-19**] echo: normal global and regional biventricular systolic function (lvef >55%). no diastolic dysfunction, pulmonary hypertension or significant valvular disease seen. no evidence of intra-cardiac shunt. [**2193-6-28**] ct chest noncontrast: 1. resolution of right lung dependent consolidation. 2. new nonspecific, widely spread patchy multifocal ground-glass and several consolidative opacities worrisome for a new infectious process. eosinophilic pneumonia is also possible considering recently provided history of eosinophilia. the peripheral distribution of several of these small consolidations also raises the possibility of embolic disease in the appropriate setting. 3. slight interval increase in mediastinal lymphadenopathy, likely reactive. 4. unchanged lower lobe mild bronchiectasis. 5. 5 mm perifissural nodule versus small amount of loculated fluid described in the previous report persists. consideration of a followup chest ct in six months is again recommended. 6. mild increase in size of bilateral small pleural effusions without pulmonary evidence for cardiogenic edema. [**2193-6-29**] bilateral lenis: 1. no evidence of dvt. 2. possible pseudoaneurysm in the left groin. recommend non-emergent vascular ultrasound for further evaluation. [**2193-7-2**]: femoral vascular u/s: left groin pseudoaneurysm. [**2193-7-2**] pmibi: no significant st segment changes over baseline and no anginal type symptoms. nuclear portion showed: 1. severe moderate-sized reversible perfusion defect involving the distal anterior wall, apex, and distal inferior left ventricular wall. 2. normal left ventricular size and systolic function, lvef=57%. brief hospital course: this is a 70 year old female with a history of cad s/p cabg, s/p hepatorenal bypass for ras presenting with fever, angina, and hypoxia. # hypoxic episodes: patient had repeated episodes of hypoxia, initially associated with chest pain throughout the first 7 days of her hospital course. she triggered three times for this chest pain and hypoxia, cards consult felt symptoms were not acs and instead secondary to demand ischemia in the setting of infection. both chest pain and hypoxia were imrpoved with ngl initially, however, hypoxia worsened to the point of requiring nrb with sats of 93%. the patient was transferred to the icu for monitoring. cxr did not show any pulmonary edema. there was no identifiable source of infection, but ct chest showed evidence of rll pna, possible aspiration. in the icu, she was started on ceftriaxone and azithromycin and her o2 sats improved. she was transferred back to the floor saturating 94% on 4l nc. bnp was 16,000. on the floor, she continued to experience episodes of chest pain with transient worsening of hypoxia that resolved with ngl and morphine and increased oxygen. she required 5l nc and 50% by facemask for the week after transfer from the unit. given her elevated bnp, she was diuresed with ethacrynic acid with good results. with diuresis, her chest pain episodes resolved. she was aggressively diuresed approximately 5 or 6l and completed a 10-day course of ctx/azithromycin/clindamycin for ? aspiration pneumonia. her o2 requirement was eventually weaned to ra. just prior to her weaning, repeat ct chest showed some peripheral ground glass opacities in all lung fields bilaterally. pulmonolgy was consulted and felt they were likely not of infectious eitology, but were perhaps due to residual edema. no specific treatment was initiated for this. on discharge the patient was breathing comfortably on ra with o2 sats > 91%. she had no evidence of desaturation when ambulating. # anginal symptoms: patient started experiencing chest pain shortly after admission. the pain was described as pressure on her chest, always preceded by jaw pain, and radiating to her back. occasionally the pain radiated into the left arm. these episodes were associated with hypoxia, but it was often difficult to determine if the chest pain preceded the hypoxia or was due to the hypoxia. her pain was initially treated with sl ngl, morphine, and oxygen. cardiac enzymes were repeatedly negative. she was continued on aspirin, beta-blocker, statin, and imdur. cxr were initially normal but then began to show volume overload. her ekg was unchanged on multiple occasions, though was difficult to interpret due to underlying conduction abnormalities. cardiology was consulted and felt that her chest pain was most likely [**12-24**] demand ischemia in setting of fever and infection. her chest pain continued on a daily basis. imdur was increased to 90 mg po qhs. after this change and with diuresis, her anginal symptoms resolved. cardiology considered cardica catheterization, but held off due to residual renal dysfunction and improvement of her symptoms with diuresis. when she had stabilized, she underwent a p-mibi which showed severe moderate-sized reversible perfusion defect involving the distal anterior wall, apex, and distal inferior left ventricular wall with normal left ventricular size and systolic function, lvef=57%. cardiology was consulted after this finding and felt that this could be medically managed for now, until her renal failure stabilized. she was continued on her aspirin, b-blocker, statin and imdur and was discharged to follow-up with cardiology. # pneumonia: on admission mrs. [**known lastname 31866**] was initially symptom free from a pulmonary standpoint. however, on the day after admission, she began to have hypoxic episodes with saturations down to 80%. cxr on admission was clear, repeat cxr showed possible rll pneumonia. she was started on ceftriaxone. on day 5 of admission she was briefly transferred to the icu due to sustained hypoxia (assocaited with chest pain, ce's negative). at the time she was on a nrb, with saturations of 93%. abg on nrb was 7.40/31/64. she was treated briefly with vanc/zosyn, however was quickly switched back to ceftriaxone with azithromycin to complete 10 day course for hcap. clindamycin was added out of concern for aspiration. she was febrile when antibiotics were discontinued, but she had no sign of active infection on exam or lab test. repeat cxr after antibiotic course showed resolution of rll pna, but edema was still present. due to continued hypoxia despite successful diuresis, a repeat ct of her chest was performed which showed ground glass opacities in the periphery of all lung fields bilaterally. initially, the concern was for infectious vs embolic etiology for these ground glass opacities, however pulmonary consult was less concerned and no intervention was made. # crf: her was cr 2.6 initially, but quickly returned to her baseline. she was given lasix when diuresis was initially attempted, but this gave pt pruritis which resolved with benedryl. due to fluid overload and the adverse reaction to lasix, mrs. [**known lastname 31866**] was diuresed with ethacrynic acid during the second week of her admission. she was treated with benadryl prn for itching with the ethacrynic as well. renal function was at baseline (cr 1.9) at discharge. # pancytopenia: hematology was consulted for her pancytopenia (wbc 3.7, hgb 9.7, plt 74k) and reviewed a peripheral blood smear. no schistocytes were seen, so this was felt unlikely to be ttp. her outpatient pentoxyfilline was discontinued due to her pancytopenia. no intervention made and her thrombocytopenia resolved. she remained anemic, not requiring transfusion. her leukopenia resolved by discharge. an outpatient f/u appt was scheduled with heme/onc. # htn: mrs.[**known lastname 31867**] hypertension was monitored in the hospital throughout her stay. she was initially hypotensive in the ed, but this responded to ivf. her b-blocker and isosorbide were continued but her doses were uptitrated. her lisinopril was decreased and her amlodipine and hctz were discontinued. her blood pressure was stable and in target range on discharge. # pulmonary nodule: on her ct scan, a 5 mm perifissural nodule versus small amount of loculated fluid was described. a followup chest ct in six months was recommended. # left groin pseudoaneurysm: she had lenis performed to rule out dvt during her hospitalization and these were without any evidence of dvt but did show a left groin pseudoaneurysm, 1.7 x 2.1 x 2.0 cm. this was felt to be stable from her previous imaging and she was advised to follow up with vascular as an outpatient. # code: dni medications on admission: aspirin 81 mg p.o. q.d. zantac 150 mg p.o. b.i.d. lopressor 25 mg p.o. b.i.d. lorazepan 0.5mg po qhs prn pravastatin 40mg po qday hydrochlorothiazine 25mg po qday lisinopril 10mg po qday ranitidine 150mg po bid citalopram 40mg po qday amlodipine 10mg po qday isosorbdin 40 mg er qday allopurinol 100mg po qday cipro 500mg po bid x 4 doses-stoped on saturday discharge medications: 1. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain : take one, if no resolution of chest pain after 5 minutes take another pill. if after 2nd pill no resolution of chest pain call 911. disp:*30 tablet, sublingual(s)* refills:*0* 2. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 3. citalopram 20 mg tablet sig: two (2) tablet po daily (daily) for 1 months. disp:*60 tablet(s)* refills:*0* 4. lorazepam 1 mg tablet sig: .5 tablet po hs (at bedtime) as needed for sleep. 5. isosorbide mononitrate 30 mg tablet sustained release 24 hr sig: three (3) tablet sustained release 24 hr po qhs (once a day (at bedtime)). disp:*90 tablet sustained release 24 hr(s)* refills:*0* 6. lisinopril 5 mg tablet sig: 0.5 tablet po daily (daily). disp:*15 tablet(s)* refills:*0* 7. pravastatin 80 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 8. metoprolol tartrate 50 mg tablet sig: 1.5 tablets po three times a day. disp:*135 tablet(s)* refills:*0* 9. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. disp:*30 capsule, delayed release(e.c.)(s)* refills:*0* 10. pentoxifylline 400 mg tablet sustained release sig: one (1) tablet sustained release po three times a day. 11. ranitidine hcl 150 mg tablet sig: one (1) tablet po twice a day. discharge disposition: home with service facility: [**company **] discharge diagnosis: primary: 1. urinary tract infection 2. pneumonia 3. diastolic heart failure secondary: 1. coronary artery disease 2. hypertension 3. gerd discharge condition: vital signs stable, satting 93% on ra, ambulating without assistance discharge instructions: you were admitted to the [**hospital1 18**] for fever and an urinary infection after having nausea and vomiting at home from taking cipro. you continued to have fever during your hospitalization, we found that you had pneumonia and treated you with antibiotics. you also had episodes of chest pain and decreases in your oxygen. in consultation with the cardiologist, we concluded that you were not having a heart attack, however you will need close follow-up with your cardiologist and pcp. [**name10 (nameis) **] also had extra fluid in your body that was removed with water pills. . medication changes: 1)increased pravastatin to 80mg by mouth daily 2)changed toprol xl to metoprolol to 75mg by mouth three times a day 3)changed ativan to 0.5 mg by mouth at bedtime 4)decreased lisinopril to 2.5mg by mouth daily 5)started imdur 90mg by mouth daily 6)started aspirin 325mg by mouth daily 7)we have discontinued isosorbide dn, amlodipine, and hydrocholorothiazide ***please discuss restarting allopurinol with your primary care doctor at your upcoming visit. . follow up appointments: md: dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] specialty: pcp date and time: thursday [**2194-7-4**]:00 am location: [**street address(2) 31868**], [**location (un) 1439**] ma phone number: [**telephone/fax (1) 22468**] . md: dr. [**first name4 (namepattern1) **] [**last name (namepattern1) **] specialty: vascular surgery date and time: thursday, [**7-11**] at 2:20pm location: [**last name (namepattern1) 439**], [**location (un) 86**], ma, [**hospital ward name **] bldg [**hospital unit name **] phone number: [**telephone/fax (1) 9645**] . md: dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] - call to confirm specialty: medical oncology date and time: tuesday [**2194-8-6**]:30am location: [**hospital1 18**], [**hospital ward name 516**], [**hospital ward name 23**] bldg, [**location (un) 24**] . if you experience chest pain, shortness of breath, fever greater than 101, palpitations, light-headedness or any other symptom that concerns you, please contact your pcp immediately or seek help at the nearest emergency room. followup instructions: md: dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] specialty: pcp date and time: thursday [**2194-7-4**]:00 am location: [**street address(2) 31868**], [**location (un) 1439**] ma phone number: [**telephone/fax (1) 22468**] md: dr. [**first name4 (namepattern1) **] [**last name (namepattern1) **] specialty: vascular surgery date and time: thursday, [**7-11**] at 2:20pm location: [**last name (namepattern1) 439**], [**location (un) 86**], ma, [**hospital ward name **] bldg [**hospital unit name **] phone number: [**telephone/fax (1) 9645**] md: dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] - call to confirm specialty: medical oncology date and time: tuesday [**2194-8-6**]:30am location: [**hospital1 18**], [**hospital ward name 516**], [**hospital ward name 23**] bldg, [**location (un) 24**]",1
45,"admission date: [**2150-10-13**] discharge date: [**2150-11-10**] date of birth: [**2086-10-30**] sex: m service: surgery allergies: tape attending:[**first name3 (lf) 1481**] chief complaint: presents for elective surgical repair of a right flank hernia. major surgical or invasive procedure: [**10-13**] right flank hernia repair with mesh [**10-14**] l3 laminectomy with scar tissue excision history of present illness: mr. [**known lastname 46422**] is a 63 year old male who presented to [**hospital1 18**] on [**10-13**] for elective surgical repair of a right flank hernia by dr. [**last name (stitle) **]. he has a past medical history significant for multiple myeloma and is s/p a decompressive laminectomy complicated by a wound infection and a radiated field requiring an omental graft which went off the abdominal wall on the right side. a ct scan demonstrated a large hernia in the abdominal wall on the lateral aspect, with a defect of 5cm. past medical history: past medical history: 1. multiple myeloma: diagnosed [**1-/2147**]; has been on monthly ivig, thalidomide, on decadron in past. monthly ivig required for frequent chronic infections. 2. recurrent pna, including mrsa (most recenly [**2148-12-2**]) 3. atrial arrhythmias (afib/flutter/sinus brady, s/p pacemaker placement 4. ?mi [**8-16**]; tte [**3-17**]- ef=50%, 1+ mr, 1+ tr, trace ar p-mibi [**9-16**]: ef=51%, nl perfusion 5. le dvt, on chronic coumadin therapy 6. dm 7. ?cva with right-sided paresis, slurred speech, ?seizure activity past surgical history: l4-s1 laminectomy, c/b mrsa infection of incision site social history: the patient lives with his fiance in [**hospital1 1474**]. he quit smoking 2 yrs ago, smoked 1.5 ppd x 30 yrs. he currently drinks infrequently; he formerly drank 30 beers/weekend he denies h/o ivdu. family history: mother-breast cancer [**name (ni) 46425**], died mi age 32 twin brother with no medical problems [**name (ni) 8765**] cad pertinent results: post-operative: [**2150-10-13**] 09:55pm blood wbc-14.9*# rbc-3.91* hgb-12.3* hct-37.4* mcv-96 mch-31.5 mchc-32.9 rdw-15.8* plt ct-180 [**2150-10-13**] 09:55pm blood plt ct-180 [**2150-10-13**] 09:55pm blood glucose-100 urean-7 creat-0.8 na-138 k-3.8 cl-104 hco3-26 angap-12 [**2150-10-13**] 09:55pm blood ck(cpk)-69 alkphos-69 [**2150-10-21**] 05:18am blood ck-mb-notdone ctropnt-<0.01 [**2150-10-13**] 09:55pm blood calcium-7.9* phos-3.1 mg-1.8 [**2150-10-13**] 10:55pm blood lactate-0.8 [**2150-10-14**] 08:02pm blood freeca-1.03* discharge: [**2150-11-8**] 05:42am blood wbc-6.7 rbc-3.21* hgb-9.8* hct-29.7* mcv-93 mch-30.7 mchc-33.1 rdw-16.7* plt ct-403 [**2150-11-10**] 05:07am blood pt-16.1* ptt-31.3 [**month/day/year 263**](pt)-1.5* [**2150-11-8**] 05:42am blood glucose-90 urean-19 creat-0.6 na-139 k-4.0 cl-108 hco3-24 angap-11 [**2150-10-22**] 04:02am blood alt-16 ast-15 alkphos-66 amylase-44 totbili-0.7 [**2150-11-8**] 05:42am blood calcium-8.5 phos-3.2 mg-2.2 [**2150-11-6**] 04:39am blood valproa-60 [**2150-11-2**] 06:03am blood valproa-14* [**2150-10-21**] 5:21 am blood culture **final report [**2150-10-27**]** aerobic bottle (final [**2150-10-27**]): escherichia coli. final sensitivities. work-up sensitivity for bactrim per dr. [**first name (stitle) **],[**doctor last name **] pager ( [**numeric identifier 21494**]). trimethoprim/sulfa sensitivity testing confirmed by [**first name8 (namepattern2) 3077**] [**last name (namepattern1) 3060**]. anaerobic bottle (final [**2150-10-23**]): reported by phone to [**doctor last name **],valesca- cc5b [**numeric identifier 24691**]- @ 1653 on [**2149-10-21**]. escherichia coli. sensitivities performed from aerobic bottle. [**2150-10-21**] 3:00 pm csf;spinal fluid site: lumbar puncture tube 3. gram stain (final [**2150-10-23**]): reported by phone to valeska artis @ 8pm on [**2150-10-21**]. 4+ (>10 per 1000x field): polymorphonuclear leukocytes. 2+ (1-5 per 1000x field): gram negative rod(s). smear reviewed; results confirmed. fluid culture (final [**2150-10-27**]): escherichia coli. rare growth. trimethoprim/sulfa sensitivity testing available on request. bactrim (=septra=sulfa x trimeth) susceptibility testing requested by dr. [**last name (stitle) **] ([**numeric identifier 21494**]) [**2150-10-25**]. sensitive to amikacin <= 2mcg/ml. trimethoprim/sulfa sensitivity testing performed by [**first name8 (namepattern2) 3077**] [**last name (namepattern1) 3060**]. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | viral culture (preliminary): no virus isolated so far. [**2150-10-22**] 1:40 pm swab lumbar spine wound. **final report [**2150-10-26**]** gram stain (final [**2150-10-22**]): this is a corrected report ([**2150-10-23**]). reported by phone to dr [**first name8 (namepattern2) **] [**last name (namepattern1) 46426**] [**2150-10-23**] at 4pm. 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): gram negative rod(s). . previously reported as. 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): gram positive cocci. in pairs and clusters ([**2150-10-22**]). wound culture (final [**2150-10-24**]): escherichia coli. sparse growth. identification and sensitivities performed on culture # [**numeric identifier 46427**] ([**2150-10-21**]). anaerobic culture (final [**2150-10-26**]): no anaerobes isolated. [**2150-10-23**] 3:30 pm blood culture **final report [**2150-10-29**]** aerobic bottle (final [**2150-10-29**]): no growth. anaerobic bottle (final [**2150-10-29**]): no growth. anaerobic bottle (final [**2150-10-30**]): reported by phone [**male first name (un) 46428**] at 2100 on [**10-26**].. staphylococcus, coagulase negative. isolated from one set only. work-up sensitivity per dr. [**first name (stitle) **],[**doctor last name **] pager ([**numeric identifier 21494**]) [**2150-10-28**]. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. vancomycin------------ <=1 s [**2150-10-26**] 10:39 am mrsa screen site: rectal source: rectal swab. **final report [**2150-10-28**]** mrsa screen (final [**2150-10-28**]): no mrsa isolated. [**2150-10-27**] 10:00 am csf;spinal fluid tube 3. gram stain (final [**2150-10-27**]): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final [**2150-10-30**]): no growth. viral culture (preliminary): no virus isolated so far. anaerobic bottle (final [**2150-11-4**]): no growth. [**2150-10-29**] 5:03 am stool consistency: soft source: stool. **final report [**2150-10-29**]** clostridium difficile toxin assay (final [**2150-10-29**]): feces negative for c. difficile toxin by eia. reference range: negative. [**2150-10-31**] 11:50 pm blood culture **final report [**2150-11-7**]** aerobic bottle (final [**2150-11-7**]): no growth. anaerobic bottle (final [**2150-11-7**]): no growth. [**2150-11-1**] 1:24 am blood culture line r-cvl. **final report [**2150-11-7**]** aerobic bottle (final [**2150-11-7**]): no growth. anaerobic bottle (final [**2150-11-7**]): no growth. [**2150-11-2**] 10:09 pm stool consistency: soft **final report [**2150-11-3**]** clostridium difficile toxin assay (final [**2150-11-3**]): feces negative for c. difficile toxin by eia. reference range: negative. [**2150-11-10**] 8:24 am stool consistency: soft source: stool. **final report [**2150-11-10**]** clostridium difficile toxin assay (final [**2150-11-10**]): feces negative for c. difficile toxin by eia. reference range: negative. operative report [**last name (lf) **],[**first name3 (lf) **] f. signed electronically by [**last name (lf) **],[**first name3 (lf) **] on [**doctor first name **] [**2150-10-15**] 11:09 am name: [**known lastname **], [**known firstname **] unit no: [**numeric identifier 46429**] service: date: [**2150-10-13**] date of birth: [**2086-10-30**] sex: m surgeon: [**first name11 (name pattern1) 333**] [**last name (namepattern4) 366**], md 2205 preoperative diagnosis: flank hernia. postoperative diagnoses: flank hernia. procedure: repair of flank hernia with mesh and division of omental graft. assistant: dr. [**first name (stitle) **] anesthesia: general. indication: this gentleman has had multiple operations for problems of myeloma decline. most recently, he had an omental graft which was harvested from the intra-abdominal cavity, brought out through a flank wound and into an open wound of the back. this was several years ago and allowed this would to heal. unfortunately, he has developed a hernia in this area. he presents now for repair. the hernia itself was large and bothersome but, more importantly, it is very large and contains a fair amount of small and large intestine, through a relatively [**name2 (ni) 15403**] defect. this does place him at risk for incarceration or strangulation. preparation: in the operating room, the patient was given general endotracheal anesthetic. intravenous antibiotics were given. catheter was placed into the bladder. the patient was placed in the left lateral decubitus position, prepared with betadine solution and draped in the usual fashion. incision: the incision was opened along the inferior aspect of one of the v-y advancement incisions and carried down to the subcutaneous tissue. findings: there was quite a large hernia sac. the defect itself was [**name2 (ni) 15403**] in size. one portion of the defect was the anterior superior iliac spine. the omental graft went through this defect. procedure in detail: the sac was dissected away from the surrounding tissue. we were then able to find the omental graft and dissect the surrounding tissues away from the edge of the fascial defect and bone defect. we took care to stay in a relatively extraperitoneal plane here and there was certainly adequate amount of coverage of the bowel and its contents with peritoneum such that we could use normal graft material. the omental graft was then divided and a section of it was removed. we thought that this would be perfectly reasonable as the defect could not be closed without removing it without a high-risk of recurrence and also that the tissue had already experienced inset for the past several years and was vascularized with surrounding focal vasculature. therefore, the graft was divided with clamps and ties of 2-0 vicryl. the defect was then measured and we placed a marlex patch as an underlay with a lot of underlay, measuring at least 3 to 5 cm underneath the fascial edges. we began the most anterior part and ran these around with running full- thickness mattress sutures. the repair was done under some tension in order to have the edges come together nicely which, indeed, they did. the tension was not excessive and came together very well. we then finished the closure by placing 4 mitek anchors into the bone. these were attached to number one sutures which were then sutured to the vasculature to close off that portion of the defect. the area was then inspected for hemostasis which was quite adequate. closure: the sac tissue was closed over the top of this in order to exclude it from the wound and also to decrease seroma formation. this was done with running suture of #2-0 pds. the subcutaneous tissue was closed with interrupted sutures of 2-0 vicryl. dermal sutures of 3-0 vicryl were then placed and a running subcuticular suture of 4-0 monocryl was then placed to close the skin. a dry sterile dressing was then applied. the patient was then extubated and sent to the recovery area in satisfactory condition, having tolerated the procedure well. drains: none. complications: none. estimated blood loss: minimal. [**first name11 (name pattern1) 333**] [**last name (namepattern4) 366**], [**md number(1) 367**] operative report [**last name (lf) **],[**first name3 (lf) **] j. signed electronically by [**last name (lf) **],[**first name3 (lf) **] j on mon [**2150-10-19**] 8:17 am name: [**known lastname **], [**known firstname **] unit no: [**numeric identifier 46429**] service: [**last name (un) **] date: [**2150-10-14**] date of birth: [**2086-10-30**] sex: m surgeon: [**first name11 (name pattern1) **] [**initial (namepattern1) **] [**last name (namepattern4) 1352**] [**numeric identifier 46430**] assistant: [**first name5 (namepattern1) 4468**] [**last name (namepattern1) 46431**] preoperative diagnosis: 1. cauda equina syndrome. 2. previous lumbar decompression. 3. diskitis. 4. vertebral osteomyelitis. 5. multiple myeloma involving the lumbar spine. 6. history of a dural tear. 7. history of a previous omental flap. postoperative diagnosis: severe stenosis at lumbar spine at l3-l4. procedure: revision decompression of the lumbar spine from l2-l3 to l5-s1. instrumentation: none. anesthesia: general endotracheal. fluids: 3300 cc. estimated blood loss: 450 cc. urine output: 450 cc. drains: two medium hemovac drains placed deep in the wound. specimens: both bone and soft tissue were sent for both pathology and microbiology. findings: severe stenosis at l3-l4 as well as to some degree at l4-l5. significant dural scar tissue. well vascularized omental flap. complications: none. sponge count: correct. indications: this is a 63 year-old gentleman who [**last name (namepattern1) 1834**] elective procedure involving the repair of a flank hernia from a previous omental flap to cover a lumbar wound. he has a complicated history with underlying multiple myeloma of the lumbar spine as well as previous lumbar decompression complicated by diskitis and osteomyelitis as well as a dural tear and revision surgery. postoperatively from the hernia repair he had progressive weakness of his right leg greater than his left leg as well as loss of rectal tone. a ct myelogram was performed as he could not have an mri because of a pacemaker. ct myelogram showed cutoff at the l3 level. there was no reconstitution of the dye column below the l3 level. based on these findings as well as clinical findings he was taken to the operating room that night 1 day following repair of his hernia. consents were signed by his health proxy, his [**name2 (ni) 18933**] secondary to the being intubated and sedated. due to the severity of the clinical findings as well as the ct myelogram it was felt that this was adequate although not optimal. procedure: consent was obtained as above. the patient was given 1 gram of vancomycin, was brought back to the operative theater and placed prone on the [**location (un) 1661**] frame. all bony prominences were carefully padded. his lumbar spine was prepped and draped sterilely in the usual fashion. he had significant scar tissue on his back from his previous omental flap and resections. the previous incision was incised and extended proximally slightly about 4 cm. this was taken down to known tissue and what was thought to be the l2 spinous process based on his ct scan. the paraspinal muscles were dissected off the l2 spinous process. the omental flap was incised and was found to be well perfused. the lamina of l2 as well as the l2-3 facet was identified. the partial l3 spinous process was then dissected and soft tissue was stripped from that. the bony anatomy in either gutter was identified down to what was thought to be l5. a lateral radiograph confirmed the levels. at that point an l3 laminectomy was performed as well as l2-l3 decompression. the l3 pedicles were well visualized. the l2- l3 foramen was felt and felt to be open. the bilateral l3 pedicles were directly visualized and the l3 exiting nerve roots were visualized after freeing up the scar tissue. this was continued distally. the l4 pedicles were visualized after freeing up the scar tissue from the lateral gutters. the dural sac was freely mobile below that. the l5 pedicles were then visualized bilaterally. on the left side there appeared to be no bone laterally that could be stripped of soft tissue as was consistent with the ct scan. on the right side there was bony tissue visualized and the l5 pedicle was visualized at that point. the dural sac at that point was felt to be freely mobile without significant posterior compression. significant ligamentum flavum and hypertrophic ligamentum flavum had been removed at the l3-l4 level. the discs and ventral dural sack could be examined at the l3-4 level to some degree. below this it was felt that the risks of a dural tear were too high versus looking for a ventral lesion. hemostasis was maintained. copious irrigation was used. two drains were placed. the deep tissue was closed with interrupted #0 vicryls. the subcutaneous with #2-0 vicryls and the skin with staples. patient was placed supine and taken to the intensive care unit without complications. [**first name11 (name pattern1) **] [**initial (namepattern1) **] [**last name (namepattern4) 1352**] 20-acn operative report [**last name (lf) **],[**first name3 (lf) **] j. signed electronically by [**last name (lf) **],[**first name3 (lf) **] j on tue [**2150-10-27**] 8:52 am name: [**known lastname **], [**known firstname **] unit no: [**numeric identifier 46429**] service: date: [**2150-10-22**] date of birth: [**2086-10-30**] sex: m surgeon: [**first name11 (name pattern1) **] [**initial (namepattern1) **] [**last name (namepattern4) 1352**] [**numeric identifier 46430**] assistant: [**first name8 (namepattern2) 803**] [**last name (namepattern1) **] preoperative diagnosis: 1. infected posterior lumbar wound with persistent dural leak. 2. multiple myeloma involving l5 and s1. 3. status post previous l2-l3 to l5-s1 lumbar decompression and revision decompression. 4. status post wound dehiscence with omental flap, persistent dural leak and infection. 5. cauda equina. postoperative diagnosis: 1. infected posterior lumbar wound with persistent dural leak. 2. multiple myeloma involving l5 and s1. 3. status post previous l2-l3, l5-s1 lumbar decompression and revision decompression. 4. status post wound dehiscence with omental flap, persistent dural leak and infection. 5. cauda equina. procedure: 1. incision and debridement lumbar wound. 2. laminotomy, right side at l2. 3. dural repair. instrumentation: none. anesthesia: general endotracheal. fluids: 1500 cc. estimated blood loss: 250 cc. urine output: 580 cc. drains: two medium hemovacs placed deep. specimens: 1. two specimens were sent to microbiology. 2. one specimen was sent to pathology which was deep tissue. findings: 1. large fluid collection just above the dura. 2. a dural tear that was the size of approximately a 20 gauge needle tip on the right side at the level of the inferior aspect of the l2 lamina as predicted on ct based on ct myelogram. complications: none. sponge count: correct. x-ray showing no retained hardware. indications: this is a 63 year old gentleman who i previously did a revision l2-l3 to l5-s1 decompression for cauda equina. he did quite well in the postoperative period. he regained his quad strength on his right and left side, although nothing distal to that. he was even scheduled and considered for rehabilitation placement. however, he developed mental status changes on postoperative day 6 and was intubated for fevers. he became septic. blood cultures grew out gram-negative rods. the a spiral chest ct was negative. chest x-ray was negative. ua was negative. ct of the head was also negative. meningitis was considered, although i thought it was unlikely. a lumbar puncture was positive for significant number of white cells as well as protein without glucose. gram-negative rods were also seen in the lumbar puncture. an aspiration of a fluid collection on a new ct of his lumbar spine also showed gram-negative rods. beta-2 transferrin levels were pending. on review with the radiologist, the previous ct monitoring done on [**10-16**], there is a dural leak that was not previously present. at that time, there was no posterior fluid collection. secondary to the fact that there was a fluid collection in his lumbar spine as well as gram negative rods, he was consented through his fiance for an i and d of his lumbar spine and at this point also could address the persistent dural leak. procedure: the patient was brought from the trauma intensive care unit intubated to the or. he was placed on [**initials (namepattern4) **] [**last name (namepattern4) 1661**] table, bony prominences carefully padded. the staples were removed. his lumbar wound was prepped and draped sterilely in the usual fashion. the incision was opened. all vicryl sutures were removed. this was taken down through the dura. the skin edges as well as the superficial and deep tissues from the wounds were freshened using curet, leksells, back to bleeding tissue. hemostasis was then obtained. the deep bone in the bilateral gutters were cleaned of soft tissue and previous gelfoam. copious pulse lavage was used including 9 liters of fluid after tissue resection had taken place. the dural leak was exactly where it was predicted by the radiologist which was on the right side just at the inferior surface of the l2 lamina. there was a poke hole and no other area of leakage was noted. a laminotomy was taken at l2 to fully expose the leakage. copious irrigation was used. when [**initials (namepattern4) **] [**last name (namepattern4) **] was placed on this hole, no other area of leakage could be identified. at that time, duragen was placed over this hole and then tisseel was used over the duragen. at this point, the wound was closed with interrupted 0 vicryls after medium hemovacs were placed deep to this. 2-0 vicryls were used in the subcutaneous tissue. the scar was removed and the skin was closed with horizontal mattress 2-0 nylons. cultures had been taken as well as a piece of tissue from the deep layer to pathology. xeroform was placed and a sterile dressing was placed. the patient was placed supine on a regular bed and taken back to the trauma intensive care unit. i talked specifically to the team. he is to stay flat for at least 3 days. he is to undergo dvt prophylaxis primarily with compression stockings. while the drains are in place, he is to continue on his antibiotics and maximize the nutrition. [**first name11 (name pattern1) **] [**initial (namepattern1) **] [**last name (namepattern4) 1352**] 20-acn radiology final report ct head w/o contrast [**2150-11-2**] 7:13 am ct head w/o contrast reason: please r/o acute bleed/infx. [**hospital 93**] medical condition: 64 year old man with acute decrease in mental status. reason for this examination: please r/o acute bleed/infx. contraindications for iv contrast: none. indication: history of e-coli bacteremia. acute decrease in mental status. comparison: ct head [**2150-10-25**]. technique: ct head without intravenous contrast. findings: there is no evidence of hemorrhage, mass, infarct, or shift of normally midline structures. the [**doctor last name 352**]-white matter differentiation is preserved. again noted a tiny focus of low density within the left parietal region adjacent to vertex, likely represents an area of chronic ischemic change. the soft tissues are stable in appearance, including a likely sebaceous cyst within the superficial scalp soft tissues posteriorly. osseous structures are stable in appearance. impression: no evidence of hemorrhage, mass, or edema. subtle areas of infection/abscess would be better demonstrated by mri. radiology final report carotid series complete [**2150-11-4**] 9:25 am carotid series complete reason: evaluate carotid arteries, hx. afib & stroke in past, now wi [**hospital 93**] medical condition: 64 year old man with hx. afib, cad, s/p right flank hernia repair [**10-13**], l3 laminectomy with scar tissue excision [**10-14**], +bacteremia and meningitis, now with mental status changes reason for this examination: evaluate carotid arteries, hx. afib & stroke in past, now with mental status changes carotid study history: afib coronary artery disease, prior stroke, mental status changes. findings: no appreciable plaque or wall thickening involving either carotid system. the peak systolic velocities bilaterally are normal as are the ica to cca ratios. there is also normal antegrade flow involving both vertebral arteries. impression: normal study. radiology preliminary report chest (portable ap) [**2150-11-9**] 4:50 am chest (portable ap) reason: sob c o2 sats 89%->92 facemask. [**hospital 93**] medical condition: 63 year old man c acute sob. reason for this examination: sob c o2 sats 89%->92 facemask. ap chest 5:25 a.m. [**11-9**] history: acute shortness of breath and hypoxia. impression: ap chest compared to [**11-6**] and 26: the patient is not intubated. lungs are fully expanded and clear. there is no pleural abnormality. cardiomediastinal and hilar silhouettes are normal. tip of the right pic line projects over the junction of the brachiocephalic veins. transvenous right atrial and right ventricular pacer leads are in standard placements. no pneumothorax. brief hospital course: mr. [**known lastname 46422**] [**last name (titles) 1834**] a repair of a right flank incisional hernia on [**10-13**] by dr. [**last name (stitle) **] and dr. [**first name (stitle) **] of plastic surgery with no intra-operative complications. post-operatively he developed right and left lower extremity weakness and decreased sensation, right > left; decreased motor and sensory apparent on exam. a neurology and spine consult was obtained and a steroid bolus was administered along with a steroid drip. a ct scan of his thoracic/lumbar/spine was obtained with abnormalities found involving the l4-s1 levels which compared to last ct of [**4-16**] findings of l4-l5 were significantly worse correlating with his exam, an mr was recommended but deferred secondary to patient's pacemaker. on hd 2 he had mild improvement in his right lower extremity, a ct myelogram was requested by the spine service to evaluate the area of maximal compression in planning for surgical decompression based on the ct findings. a nephrology consult was obtained for clearance of ct myelogram secondary to his pmh of multiple myeloma, his creatinine was normal at 0.7 and he had adequate urine output; he was cleared to receive contrast and [**date range 1834**] a ct myelogram on hd 2. on hd 2 he was then taken back to the operating room and [**date range 1834**] a revision decompression of the lumbar spin from l2-l3 to l5-s1 with the findings of severe stenosis at lumbar spine l3-l4 by the spine service with no intra-operative complications. post-operatively he was transferred to the surgical intensive care unit; he was intubated, sedated, with intravenous hydration through a central venous catheter, dilaudid pca, foley catheter, and surgical drain. the steroids were discontinued as recommended by the spine service. he was hemodynamically stable, afebrile, on vancomycin for a total of 3 doses, and receiving insulin coverage by a sliding scale. on hd 3 his pacemaker magnet was removed and he was adequately paced. on hd 3 he was extubated without difficulty and [**date range 1834**] a repeat ct myelogram with findings of improvement of spinal canal stenosis, with moderate degree stenosis remaining at l3/l4 level secondary to herniated disc. the spinal service reviewed myelogram with no further interventions recommended since there was no critical stenosis remaining. on exam he had trace movement of his right and left hips but no movement distally, deep vein thrombosis treatment was initiated with subcutaneous heparin. physical and occupational therapy were consulted at this time. on hd 4 he was transferred to an in-patient nursing unit, his diet was advanced, his pain was controlled on intravenous dilaudid and remained afebrile. on hd 6 he continued to have improvement in his quadriceps muscles bilaterally with minimal sensation of his lower extremities, from knee to toes. on hd 9 he developed sepsis with tachycardia, hypotension, febrile, hypoxia, and mental status changes. he was intubated, broad spectrum antibiotics were initiated, he received fluid resuscitation, cultures were sent, a lumbar puncture was performed via fluoroscopy, and he was transferred to the intensive care unit. cultures from blood, wound, and cerebrospinal fluid demonstrated e.coli with sensitivity to ciprofloxacin and ceftazidime, and persistent mrsa osteomyelitis. he had leukocytosis with a white blood cell count of 18k. on hd 10 he [**date range 1834**] a ct myelogram which demonstrated a dural leak, he was taken back to the operating room with findings of a infected dural leak, wound dehiscence with omental flap, and cauda equina syndrome; he [**date range 1834**] a laminotomy revision of l2, incision and drainage, and dural repair. an infectious disease consult was placed with recommendations of continuation of vancomycin, ciprofloxacin, and ceftazidime. on hd 12 he was successfully extubated, the ciprofloxacin and vancomycin were discontinued after final sensitivities were reported, he was awake with diminished mental status function. he was hemodynamically stable with a hematocrit of 26, tube feeds were initiated via a dobbhoff tube, and he was receiving subcutaneous heparin and pneumoboots for dvt prophylaxis, he had movement of his lower extremities at his thighs bilaterally; bilateral lower extremity ultrasound was negative for thrombosis. on hd 14 his white blood cell count had continued elevation to 23k, his mental status was still without improvement, he was afebrile, oxygenating well on nasal cannula; a head, spine, and chest ct scans were done with nonfocal abnormalities and stable findings, negative for pulmonary embolus; stool cultures were negative for c. diff although he was placed on empiric flagyl, a repeat lumbar puncture was performed at the level of l2-l3 with no bacteria identified. on hd 17 he had improvement in his mental status, his white blood cell count had decreased to 13k, an [**date range 461**] demonstrated his ejection fraction to be 70%. on hd 18 anticoagulation therapy was resumed with lovenox secondary to his past medical history of deep vein thrombosis, the flagyl was discontinued. on hd 19 he was transferred to an in-patient step down nursing unit, he was afebrile, and his diet was slowly advanced along with continuation of the tube feeds. on hd 20 he was found to be unresponsive to command with stable vital signs and a white blood cell count of 13k, a head ct scan was negative for acute changes or bleeding, an ekg and cardiac enzymes were negative for ischemia, an eeg showed mild encephalopathy without epileptiform; his valproic acid level was found to be sub-therapeutic, he was bolussed with adjustments made in his daily dose and improvement was noted in his mental status. a picc line was placed for a total of 4 week course of ceftazidime, until [**11-18**], and bactrim ds was re-initiated for life long suppressive therapy for enterobacter/mrsa. on hd 23 a carotid ultrasound was performed which was negative for carotid stenosis, coumadin therapy was resumed. on hd 26 calorie counts were initiated with oral intake encouraged, tube feeds were stopped, he was evaluated by speech and swallow therapy without evidence of aspiration or dysphagia; he received his monthly dose of ivig for his multiple myeloma without adverse reactions. on hd 28 he had an episode of supraventricular tachycardia which resolved spontaneously with desaturation to 90% on room air, ekg was without ischemia, chest x-ray was without changes or pneumothorax, his oxygenation improved with nasal cannula, he was afebrile without leukocytosis. he was followed by physical therapy throughout his hospitalization with recommendations of continued therapy to increase his balance and transfer training, strength, and functional mobility. his lower extremity strength was still limited, with the right less than the left at the time of discharge. his mental status had improved at time of discharge, he was oriented x 3, able to verbally communicate along with following commands. the tube feeds were discontinued and he was tolerating a regular diet with ensure supplemenentation, his calorie counts were averaging 900 calories per day, he was encouraged to increase his caloric and protein intake. he continued to have loose bowel movements, c.diff samples were negative to date, he was started on imodium which was to be continued upon discharge to [**location (un) 38**]. upon discharge to [**location (un) 38**] his pain was well controlled with oxycodone elixir, he was afebrile, and was to continue the ceftazidime until [**11-18**]. his valproic acid level stabilized at 30. he was continued on lovenox and coumadin with daily checks of his coagulation, at the time of discharge his [**month/day (4) 263**] was 1.5, he had been receiving coumadin 4mg daily. his back staples were to be removed on [**11-12**], he was discharged with the foley catheter which will be necessary for up to 6 weeks secondary to the cauda equina syndrome. he was discharged in stable condition to [**hospital 38**] rehabilitation facility on [**11-10**]. medications on admission: oxycontin oxycodone lasix potassium glyburide amiodarone depakote advair neurontin protonix bactrim synthroid discharge medications: 1. insulin sliding scale sig: insulin sliding scale every six (6) hours: fingerstick q6hinsulin sc sliding scale q6h regular glucose/insulindose 0-60 mg/dl [**12-15**] amp d50 61-119 mg/dl 0 units 120-139 mg/dl 2 units 140-159 mg/dl 3 units 160-179 mg/dl 4 units 180-199 mg/dl 5 units 200-219 mg/dl 6 units 220-239 mg/dl 7 units 240-259 mg/dl 8 units 260-279 mg/dl 9 units 280-299 mg/dl 10 units 300-319 mg/dl 11 units 320-339 mg/dl 12 units 340-359 mg/dl 13 units > 360 mg/dl notify m.d. . 2. fluticasone-salmeterol 100-50 mcg/dose disk with device sig: one (1) disk with device inhalation [**hospital1 **] (2 times a day). 3. acetaminophen 160 mg/5 ml solution sig: twenty (20) ml po q4-6h (every 4 to 6 hours) as needed for fever or pain. 4. ranitidine hcl 15 mg/ml syrup sig: ten (10) ml po bid (2 times a day). 5. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 6. enoxaparin 100 mg/ml syringe sig: 0.9 ml subcutaneous q12h (every 12 hours). 7. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls po q4-6h (every 4 to 6 hours) as needed for pain. 8. levothyroxine 25 mcg tablet sig: one (1) tablet po daily (daily). 9. oxycodone 5 mg/5 ml solution sig: ten (10) ml po q4-6h (every 4 to 6 hours) as needed for pain. 10. divalproex 125 mg capsule, sprinkle sig: one (1) capsule, sprinkle po tid (3 times a day). 11. erythromycin 5 mg/g ointment sig: 0.5 ointment ophthalmic qid (4 times a day). 12. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po bid (2 times a day). 13. gabapentin 300 mg capsule sig: three (3) capsule po q8h (every 8 hours). 14. zolpidem 5 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 15. loperamide 4 mg capsule sig: one (1) capsule po qid (4 times a day) as needed for diarhea, maximum 16mg in 24 hours, hold for constipation. 16. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day): hold for hr < 60 hold for sbp < 95. 17. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours). 18. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). 19. ceftazidime-dextrose (iso-osm) 2 g/50 ml piggyback sig: two (2) gm intravenous q8h (every 8 hours): until [**11-18**], last dose that evening of [**11-18**]. 20. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) ml intravenous daily (daily) as needed: 10ml ns followed by heparin for picc line. 21. hydralazine 20 mg/ml solution sig: one (1) ml injection q4-6h (every 4 to 6 hours) as needed for for sbp > 160: for sbp > 160. 22. other sig: coumadin dosing at bedtime: coumadin dosing by md [**first name (titles) 18303**] [**last name (titles) 263**] b/w [**1-16**]. 23. other sig: pt, ptt, [**month/day (3) 263**] once a day: daily pt, ptt, [**month/day (3) 263**] for coumadin dosing. 24. valproic acid level sig: valproic acid level once a week: check valproic acid level once a week, adjust dose accordingly . 25. coumadin 4 mg tablet sig: one (1) tablet po once: give pm [**11-10**] for [**month/year (2) 263**] of 1.5 will need daily dosing by md. discharge disposition: extended care facility: [**hospital3 1107**] [**hospital **] hospital - [**location (un) 38**] discharge diagnosis: right flank hernia cauda equina syndrome e. coli bacteremia and meningitis dural leak multiple myeloma mrsa atrial fibrilllation discharge condition: stable discharge instructions: notify md/np/pa/rn at rehabilitation facility or return to the emergency department if you experience: *increased or persistent pain not relieved by pain medication *fever > 101.5 or chills *decreased sensation or strength in upper extremities *nausea, vomiting, diarrhea, or abdominal distention *inability to pass gas or stool *if incision appears red or if there is drainage *any other symptoms concerning to you followup instructions: follow-up with dr. [**last name (stitle) **] in 2 weeks, call [**telephone/fax (1) 2981**] for an appointment completed by:[**2150-11-10**]",0
46,"admission date: [**2172-3-24**] discharge date: [**2172-3-30**] date of birth: [**2152-10-20**] sex: m service: [**doctor last name 1181**] admission diagnosis: liver failure due to acetaminophen overdose. history of present illness: the patient is a 19-year-old male with history of polysubstance abuse/dependence, who presented to outside hospital with nausea and vomiting secondary to intentional tylenol and motrin overdose. patient is being transferred back to general medicine floor after a second short micu stay. on [**2172-3-19**], the patient was in a motor vehicle accident, which totalled uncle's girlfriend's car. uncle is quite upset and chastised him. in addition to this, the patient had been feeling more depressed over the past few weeks due to legal problems. on [**2172-3-20**], the patient impulsively took 50-100 tablets of tylenol as well as motrin. from [**3-20**] until [**3-23**], the patient felt sick and went to outside hospital emergency department 2-3x before admitting to his acetaminophen overdose when a tox screen returned positive for tylenol. tylenol level on admission to outside hospital emergency department was 44.75 with alt of 14,064, ast of 7,042. the patient was also found to have acute renal failure, possibly due to motrin overdose. that same day, the patient was transferred to [**hospital1 **] micu, and given mucomyst x15 doses. while in the micu, the patient was evaluated by transplant, liver service, toxicology, and psychiatry. according psychiatric consult, the patient now regrets the od and does not want to die. seemed relieved when told there was a chance of survival. in the micu, his lfts trended down, no acidosis or encephalopathy, lactate 3.2, creatinine 2.3, inr of 5.7. thus, the patient is determined not to be a candidate for an urgent transplant, and on [**2172-3-25**], he was transferred to general medicine floor. the patient's liver enzymes continued to trend downward and arf improved with hydration. the patient was then transferred back to the micu overnight for closer observation. overnight, his condition continued to improve. today he developed cellulitis in the left hand from iv and was started on keflex 500 mg iv q8h. the patient was seen by liver service, which recommended switching to oral mucomyst. this evening he was transferred back to the general medicine floor. past medical history: mild asthma. the patient is on no medications for this. medications upon transfer: 1. acetylcysteine 20%, 6,000 mg po q4h. 2. cephalexin 500 mg po q6. 3. pantoprazole 40 mg po q24. 4. docusate sodium 100 mg po bid. 5. senna one tablet po hs. 6. ondansetron 2-4 mg iv q6 prn. 7. insulin-sliding scale per insulin flow sheet. allergies/adverse reactions: no known drug allergies. social history: the patient left high school [**male first name (un) 1573**] and is studying to get a ged. he is single, never married, no children, no current girlfriend. the patient has two sisters, and is currently living with mother. [**name (ni) **] grew up in a home with alcoholism and violence. drug use began as a teen and has involved heavy use of cocaine, lsd, ecstasy, marijuana, and heroin. the patient denies alcohol abuse, recent detox for heroin. has used needles, and has a history of multiple arrests for various charges, but never incarcerated. family history: no family history of liver disease. physical examination: patient's vital signs: temperature 99.0, pulse 58, blood pressure ranging from 120-140 systolic and 50-80 diastolic, respiratory rate 14, and o2 saturations is 98% on room air. general appearance: patient appeared stated age, alert, cooperative, and within no apparent distress. skin: jaundice, normal hair distribution, multiple ecchymoses on arms. heent: normocephalic, atraumatic, scleral icterus, no nystagmus. extraocular eye movements full. pupils are equal, round, and reactive to light. lips and membranes unremarkable. pharynx benign. no tonsillar exudates. neck is supple, full range of motion, no thyromegaly. lungs are clear to auscultation and percussion, no crackles/rhonchi/rubs/wheezing. cardiovascular: s1, s2 normal intensity, no jugular venous distention, no clicks/murmurs/rubs. abdomen: soft, nontender, diminished bowel sounds. liver span within normal limits. extremities: left hand: 2+ edema, tender to palpation, erythema on dorsum of hand, radial/popliteal/dorsalis pedis/posterior tibial pulse 2+ bilaterally, no cyanosis, no clubbing, and no edema. neurologic: cranial nerves ii through xii are grossly intact. motor: muscle bulk and tone within normal limits. strength 3/5 bilaterally and throughout. coordination: fine and repetitive finger movements intact. mental status examination: patient is alert and oriented to person, place, and time. mental status examination within normal limits. laboratories and diagnostics: complete blood count: white count 5.2, hemoglobin 13.1, hematocrit 37.5, platelets 112. pt 19.3, ptt 38.2, inr 2.5. blood chemistries: sodium 137, potassium 3.3, chloride -105, bicarb 23, bun 22, creatinine 1.6, glucose 91. calcium 8.7, phosphate 2.5, magnesium 1.9, alt 2593, ast 297, ld 299, alkaline phosphatase 130, t bilirubin 14.0. hospital course: a 19-year-old man with a history of polysubstance abuse/dependence, who presented to outside hospital with nausea and vomiting secondary to intentional acetaminophen and motrin overdose. the patient is transferred to [**hospital1 69**] with liver failure and acute renal failure. 1. gastrointestinal: on admission to outside hospital, acetaminophen level of 44.75 with alt of 14,064 and ast of 7,042. patient transferred to [**hospital3 **] micu on [**2172-3-24**] with liver failure and inr of 5.7. the patient was placed on iv mucomyst and ivf. the patient responded well to iv mucomyst with lfts trending down and was subsequently transferred to the medicine floor on [**2172-3-25**]. liver consult felt that patient was not an urgent candidate for transplant and toxicology recommended use of mucomyst until the patient's inr was less than 2. on the floor, the patient's lfts continued to trend down but the patient determined to need closer monitoring, and was transferred back to the micu that same day. the patient was transferred back to the medicine floor on [**2172-3-26**], and placed on po mucomyst, bowel regimen, and continued ivf. from [**date range (1) **], the patient's lfts continued trending down, and on [**3-29**], the patient's inr was less than 2.0. the patient's t bilirubin fluctuated from 12 to 14 during this time, and he experienced occasional bouts of nausea mostly related to mucomyst ingestion. in addition to this, the patient had no abdominal pains and all stools were guaiac negative. mucomyst was discontinued on [**3-29**]. on [**3-30**], the patient was discharged to home with followup with pcp. 2. renal: patient transferred to [**hospital3 **] micu on [**2172-3-24**] with acute renal failure and creatinine of 2.3. acute renal failure likely secondary to nonsteroidal anti-inflammatories overdose. the patient was treated supportive with ivf from [**3-24**] to [**3-28**]. ivf was discontinued on [**3-28**]. during this time, the patient's renal function gradually improved from a creatinine of 2.3 to 1.6, and continued to remain around 1.6 on discharge. patient will have follow up with primary care physician regarding renal function. 3. (id): during second micu stay, the patient developed left hand cellulitis, possibly from his iv. the patient was placed on renally dosed cephalexin 500 mg po q6h on [**2172-3-26**] x7 days. from [**date range (1) 47979**] resolved without complications. on [**3-30**], only slight swelling visible in left hand. the patient will continue with antibiotics for three more days outpatient. 4. (psych): patient is seen by psychiatry on admission and setup with one-to-one sitter. psychiatry determined that the patient regretted the overdose and did not want to die. the patient was relieved when told of chance of survival. sitter was discontinued on [**3-28**] per second recommendation. the patient will have intensive followup in outpatient psychiatric facility. condition on discharge: stable. discharge status: home with outpatient psychiatric followup. discharge diagnoses: 1. acetaminophen overdose. 2. hepatitis from acetaminophen suicide attempt. discharge medications: 1. diphenhydramine hcl 25 mg po q6h prn. 2. pantoprazole sod sesquihydrate 40 mg po q day x10 days. 3. cephalexin monohydrate 500 mg po q6h x3 days. 4. docusate sodium 100 mg po bid x7 days. 5. ursodiol 300 mg po tid x7 days. follow-up plans: 1. the patient will follow up with new primary care physician, [**last name (namepattern4) **]. [**last name (stitle) **] located in [**street address(2) 47980**], unit b210, [**location (un) 47981**], [**numeric identifier 47982**]. 2. psychiatric outpatient facility, metalsedge recovery center, [**street address(2) 47983**], [**location (un) 47981**], [**numeric identifier 47984**]. [**first name8 (namepattern2) **] [**first name4 (namepattern1) 1775**] [**last name (namepattern1) **], m.d. [**md number(1) 1776**] dictated by:[**last name (namepattern1) 9336**] medquist36 d: [**2172-3-30**] 15:25 t: [**2172-4-1**] 13:52 job#: [**job number 47985**] cc:[**telephone/fax (1) 47986**]",0
47,"admission date: [**2102-5-15**] discharge date: [**2102-5-17**] date of birth: [**2051-2-6**] sex: m chief complaint: chief complaint was question choreoathetosis. history of present illness: the patient is a 51-year-old patch 50 mcg per hour, who states he took benadryl the evening prior to admission and subsequently had uncontrollable arm and leg movements. he went to [**hospital3 15174**]. per the notes there, the patient had complained of back pain and ""itchy feet"" that resolved. the patient was noted to have athetosis. a dr. [**first name4 (namepattern1) **] [**last name (namepattern1) **], and it was felt that the patient could have been having an adverse reaction to the fentanyl and benadryl as a rare side effects of these medications is athetosis. the patient was initially treated with benadryl prior to them discovering that this may have been causing his symptoms with worsening of his symptoms. he then was given ativan for a total of 26 mg. he also received morphine, narcan, and 5 mg of intravenous valium. the patient was noted to have some improvement in his movements, but also developed agitation requiring four-point restraints. he was then transferred to [**hospital1 69**] where he was admitted to the medical intensive care unit. on arrival here, his temperature was 99.2. his other vital signs were stable. it was decided to stop using ativan for his movement disorder, and he was changed to droperidol to block dopamine. at the time of arrival, he denied any pain, and he was unable to recall the events of the evening prior. past medical history: 1. history of vicodin abuse in the past; subsequently on a fentanyl patch. 2. depression. 3. chronic low back pain. 4. question of hepatitis c; which the patient states he obtained secondary to a blood transfusion during parotid surgery. medications on admission: medications at home included a fentanyl patch 50 mcg. allergies: the patient has no known drug allergies. social history: the patient is currently staying with his mother [**name (ni) 41643**] [**name (ni) 41644**] (telephone number [**telephone/fax (1) 41645**]), as he states he is afraid to stay in his own apartment secondary to fears about the insulation causing all of his health problems. [**name (ni) **] smokes one pack of cigarettes per day. he denies any alcohol use. he states that he smoked marijuana in the remote past but denies any current use. he denies any history of intravenous drug use. physical examination on presentation: temperature was 101, blood pressure of 135/66, heart rate of 85, oxygen saturation of 96%. in general, the patient was somnolent but easily arousable to voice. head, eyes, ears, nose, and throat showed the sclerae to be anicteric. pupils were equal, round and reactive to light. extraocular movements were intact. the oropharynx was slightly dry. the neck was supple. there was no jugular venous distention, and no lymphadenopathy. the lungs were clear to auscultation bilaterally. the heart had a regular rate and rhythm. no murmurs, rubs or gallops. the abdomen was soft, nontender, and nondistended. there were normal active bowel sounds. there was no hepatosplenomegaly. the extremities were without clubbing, cyanosis or edema. neurologic examination showed the patient to be somnolent but easily arousable. he was oriented to ""[**hospital3 **]"" and [**2102-5-15**]."" he answered simple questions and moved all extremities. cranial nerves ii through xii were grossly intact. his toes were downgoing bilaterally. deep tendon reflexes were 2+ throughout. pertinent laboratory data on presentation: laboratories from the outside hospital showed a white blood cell count of 7.8, hematocrit of 46.8, platelets of 213. sodium of 139, potassium of 4.1, chloride of 101, bicarbonate of 27, blood urea nitrogen of 16, creatinine of 0.7, blood sugar of 108. calcium of 9.4, albumin of 3.8, alt of 119, ast of 45, alkaline phosphatase of 68. creatine kinase of 451, with a mb index of 1. on arrival to [**hospital1 69**] the patient's sodium was 144, potassium of 4, chloride of 109, bicarbonate of 24, blood urea nitrogen of 15, creatinine of 0.6, blood sugar of 84. alt was 95, ast was 76, amylase of 41, alkaline phosphatase of 59. creatine kinase of 2526, lipase of 6. lithium level was less than 0.2. toxicology screen was positive for barbiturates and opiates. a strychnine level was pending at the time of admission. radiology/imaging: a head ct showed no acute process. hospital course: in summary, the patient is a 51-year-old male who was admitted to the [**hospital1 188**] with what was felt to be an adverse reaction to fentanyl and benadryl administration. he was originally admitted to the medical intensive care unit for observation after he had received a lot of benzodiazepines as well as droperidol. in the medical intensive care unit, the patient was noted to have rising creatine kinases with a negative mb index and an elevated temperature. he was transferred out to the general medical floor on the second hospital day in stable condition with a decreased temperature, and no further abnormal movements. 1. neurology: a neurology consultation was obtained when the patient was first admitted given that he had fever and mental status changes. it was felt that the patient's abnormalities were most likely secondary to a medication reaction, as they promptly resolved after withdrawal of the offending agents. the question of a lumbar puncture was raised, but given the patient's lack of neurologic findings, lack of meningeal signs, and quick resolution of fever without antibiotics, no lumbar puncture was ever obtained. the question of possible neuroleptic malignant syndrome was considered given the patient's clinical presentation. however, the patient adamantly refused taking any neuroleptic medications. the patient's primary care physician was not aware of the patient taking any current neuroleptic medications as well. 2. psychiatry: as stated, the patient was exhibiting delusional behavior. he was preoccupied about formaldehyde insulation that was present in his subsidized apartment. he denied any auditory or visual hallucinations. he stated that he felt like he was depressed but denied any active suicidal ideation, but stated that he did think about hurting himself from time to time but could ""never do it."" he indicated that he had, in the past, been under the care of a psychiatrist. his primary care physician was [**name (ni) 653**] regarding his baseline mental status, and it was found that this has been a long-term issue for him, and that she has seen him three times in the past, and he has exhibited this same type of behavior at her office. in fact, he even brought a sample of powder which he said was the offending [**doctor last name 360**] into her office at one point. a psychiatry consultation was called to assess for the patient's safety to be discharged on the third hospital day. they felt the patient did seem paranoid and delusional but was not at risk of harm to himself or others and was safe to be discharged. they recommended outpatient psychiatric treatment if the patient would agree to it. i spoke to the patient's primary care physician, [**name10 (nameis) **] she stated that she would attempt to get the patient into a program given the findings above. 2. gastrointestinal: the patient also reported a history of hepatitis c that he stated was secondary to a blood transfusion that he received. hepatitis serologies and ultimately came back showing him to indeed be hepatitis c positive. in addition, serologies were consistent with past exposure to hepatitis b with hepatitis b surface antibody and hepatitis b core antibody both positive; but hepatitis b surface antigen negative. the patient's ast and alt were mildly elevated while admitted. he also described a history of a 40-pound to 50-pound weight loss over the past one to two years as well as anorexia and chronic nausea and vomiting. he did not have any stigmata of chronic liver disease on physical examination, however. given his weight loss and long-term history of hepatitis with elevated liver enzymes, there was concern for hepatoma. i spoke with the patient's primary care physician and informed her of the hepatitis serology results as well as the fact that his liver enzymes were elevated. she stated she would get the patient referred to gastroenterology. 3. infectious disease: as stated, the patient had a temperature at the time of admission after he had significant agitation and muscular rigidity secondary to his presumed drug reaction. he never had an elevated white blood cell count. he had been afebrile for more than 24 hours at the time of this discharge summary. there was concern for possible urinary tract infection, as a urine sample which had been sent while a foley was in place showed a significant amount of blood with white blood cells present. however, there were no bacteria seen, and there was a significant amount of red blood cells consistent with trauma from the foley. a repeat urinalysis was sent when the foley was removed, and this showed still blood present but no nitrites and no leukocyte esterase. there were no bacteria seen on microscopy. it was felt that his urine findings were most likely secondary to trauma from the foley and not infection. his cultures have remained negative. blood cultures have remained negative as well. stool cultures were negative for clostridium difficile, salmonella, and shigella. 4. renal: the patient did have a rise in his creatine kinase amount after having his initial episode of agitation and significant thrashing about with injury to his arms and legs when he was in the four-point restraints. his creatine kinases peaked at 8868 on the second hospital day, and on the third hospital day they were trending down. at the time of this discharge summary the most recent creatine kinase was 5569. there was another creatine kinase pending for this afternoon. if it is still trending down, the patient will be discontinued from his intravenous fluids. his renal function had remained stable with a stable blood urea nitrogen and creatinine. 5. communications: the patient's primary care physician [**last name (namepattern4) **]. [**first name4 (namepattern1) **] [**last name (namepattern1) 41646**] (at telephone number [**telephone/fax (1) 41647**]) was [**telephone/fax (1) 653**] throughout the [**hospital 228**] hospital stay and informed of the events which occurred. condition at discharge: condition on discharge was stable. medications on discharge: the patient was to be given a prescription for vicodin one to two tablets p.o. q.6h. p.r.n. for back pain. he was given a prescription for 10 pills. discharge followup: the patient was to follow up with his primary care physician, [**last name (namepattern4) **]. [**last name (stitle) 41646**], within one week following discharge. he will need further evaluation for pain control and possibly a chronic pain unit consultation to help manage his back pain. in addition, he will need follow up for his hepatitis c and elevated liver enzymes. he also needs psychiatric followup of his likely delusional disorder. discharge diagnoses: 1. choreoathetosis secondary to fentanyl/benadryl. 2. hepatitis c. 3. chronic low back pain. 4. delusional disorder. [**first name11 (name pattern1) 4283**] [**last name (namepattern4) 4284**], m.d. [**md number(1) 7551**] dictated by:[**last name (namepattern1) 6859**] medquist36 d: [**2102-5-17**] 13:47 t: [**2102-5-18**] 08:34 job#: [**job number 27843**] cc:[**numeric identifier 41648**]",1
48,"admission date: [**2175-10-7**] discharge date: [**2175-10-9**] date of birth: [**2141-6-17**] sex: f service: medicine allergies: tramadol attending:[**first name3 (lf) 338**] chief complaint: nausea, vomiting, hyperglycemia major surgical or invasive procedure: none history of present illness: ms. [**name13 (stitle) 6129**] is a 34 year old woman with dm type 1 and hashimoto's thyroiditis who presented to the ed with nausea, vomiting, and hyperglycemia concerning for dka. she took tramadol the night before admission for r shoulder pain and has been nauseous and vomiting since that time. she has been unable to take anything by mouth. since then she has noted a high blood sugars over the past 24 hours. she uses an insulin pump and has been taking her insulin and bolusing frequently, but finger stick blood glucose remained in the high 300s to low 400s, so she became concerned that that she was in dka. she has been in dka a few times in the past and was worried that she would be unable to keep up with her fluid requirements given her nausea and vomiting, so she came into the ed. she attributes the nausea to the tramadol. she denies recent illness, fevers, diarrhea, [**name13 (stitle) **], shortness of breath, chest pain, abdominal pain, rashes, dysuria, uri symptoms, or sick contacts. in the ed, initial vital signs were: t 97 hr 102 bp 116/75 rr 20 o2 sat 98% ra, pain 10. on admission, finger stick blood glucose was 349. labs were notable for serum glucose of 383, urinalysis with 1000 glucose and 150 ketones. lactate was 2.1. lytes were notable for potassium of 5.1, bicarb of 14 and ag of 20. white count of 11.0 with a left shift. she was given lorazepam 2 mg x 2, zofran 4 mg x 1, 2.5 l ns with potassium, and 8 units iv insulin and gtt at 5 units per hr (since 8pm). for access, she has two 18 gauge peripheral ivs. on arrival to the micu, vital signs were t 98.4 hr 103 bp 99/43 rr 20 o2 100% . she was comfortable, noting that her nausea and vomiting had resolved and she was feeling much better. she clearly reported the history above and denied any additional symptoms. finger stick blood glucose was 228 on arrival to the [**hospital unit name 153**]. review of systems: (+) per hpi, also notes right shoulder pain. (-) denies fever, recent weight loss or gain. denies vision changes, headache, sinus tenderness, rhinorrhea or congestion. denies shortness of breath, [**hospital unit name **], or wheezing. denies chest pain, chest pressure, palpitations. denies constipation, abdominal pain, diarrhea, dark or bloody stools. denies dysuria or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: - diabetes, type 1 (on insulin pump) - hashimoto's thyroiditis social history: lives with husband, two children, and dog and works as a stay at home mom. she denies tobacco or illicit drugs. endorses rare alcohol. family history: father died from adrenal failure, also had hypertension. mother alive and healthy. no family history of diabetes or heart disease. physical exam: admission physical exam: vitals: t 98.4 hr 103 bp 99/43 rr 20 o2 100% general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, ii/vi systolic ejection murmur loudest at the base, no rubs or gallops lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. pertinent results: admission labs: [**2175-10-7**] 06:00pm blood wbc-11.0 rbc-4.44 hgb-14.8 hct-45.1 mcv-102* mch-33.3* mchc-32.7 rdw-11.9 plt ct-450* [**2175-10-7**] 06:00pm blood neuts-91.6* lymphs-7.2* monos-0.6* eos-0.2 baso-0.3 [**2175-10-7**] 06:00pm blood glucose-383* urean-28* creat-0.9 na-136 k-5.1 cl-102 hco3-14* angap-25 [**2175-10-7**] 06:00pm blood calcium-9.8 phos-5.2* mg-2.1 [**2175-10-8**] 12:28am blood type-[**last name (un) **] po2-194* pco2-28* ph-7.27* caltco2-13* base xs--12 comment-green top [**2175-10-7**] 06:15pm blood lactate-2.1* micro: none studies: [**2175-10-7**] cxr: the heart size is normal. the mediastinal and hilar contours are unremarkable. lungs are clear and the pulmonary vascularity isnormal. no pleural effusion or pneumothorax is present. no acute osseous abnormalities are detected. impression: no acute cardiopulmonary abnormality. brief hospital course: 34 year old woman with dm type 1 and hashimoto's thyroiditis who presented to the ed with nausea, vomiting, and hyperglycemia concerning for dka, admitted to the [**hospital unit name 153**] for insulin drip. # dka: patient with type 1 diabetes diagnosed in [**2163**]. she follows with dr. [**first name4 (namepattern1) **] [**last name (namepattern1) 3636**] at [**last name (un) **] and has very good glucose control at baseline (reports a1c in the 5 range). she was felt to be in dka given persistently high fsbg readings at home, nausea, vomiting, electrolytes demonstrating an anion gap of 20, and urinalysis with glucose and ketones in the urine on arrival to the ed. vbg was notable for ph 7.27 and co2 28. the etiology of her dka is likely secondary to nausea, vomiting, and resulting hypovolemia from adverse reaction to tramadol that she had taken for shoulder pain. unlikely infectious given that she is afebrile without any localizing symptoms, no dysuria, clean urinalysis (other than glucose and ketones), no rashes, no recent illness or sick contacts, no [**name2 (ni) **] and clear chest x-ray. serum glucose on arrival ranged from 350 - 400. she was started on an insulin drip at 5 units per hour and was bolused 3 l ns in the ed. as her serum glucose fell below 200, she was transitioned to d5 water with prn boluses of ns. lytes were measured q2 hours until gap resolved the following morning and d5 was discontinued. potassium remained within the range of 4.5 to 5.0 with repletion. she was seen by [**last name (un) **], who recommended restarting her home insulin pump at 0.7 units per hour basal with i:[**doctor last name **] 1:15, cf 40, and target of 120. she remained hyperglycemic on these settings, [**first name8 (namepattern2) **] [**last name (un) **] recommended increasing her basal rate to 0.9 units/hr, i:[**doctor last name **] to 1:12 and cf to 35. she was scheduled for a follow up appointment with [**last name (un) **]. # right rotator cuff pain: patient has rotator cuff injury for which she is seeing ortho. she has outpatient cortisone injection scheduled for early [**month (only) 359**]. she was prescribed tramadol (which she had never taken) for pain refractory to ibuprofen, and developed nausea and vomiting which likely precipitated dka (above). she was continued on ibuprofen, started on acetaminophen standing, and instructed on physical therapy exercises to help with pain and range of motion. she has ortho follow up already scheduled for early [**month (only) 359**]. # hashimotos thyroiditis: she is euthyroid on exam and was continued on her home dose of levothyroxine 50 mcg po daily. # insomnia: patient recently started taking zoloft for insomnia. she denies symptoms of depression. # fen: ivf, replete electrolytes, insulin drip # prophylaxis: sqh, pneumoboots # contact: [**name (ni) 4906**] [**telephone/fax (1) 43474**] # code: full (confirmed) # transitional issues: - patient will need close pcp/endocrine follow up given dka - basal settings for insulin pump changed in consultation with [**last name (un) **]: 0.9 units/hr, i:[**doctor last name **] to 1:12 and cf to 35 -- this should be discussed with [**last name (un) **] provider at follow up appointment medications on admission: preadmission medications listed are correct and complete. information was obtained from patient. 1. levothyroxine sodium 75 mcg po daily 2. ibuprofen 800 mg po q8h:prn pain 3. sertraline 50 mg po daily 4. insulin pump sc (self administering medication)insulin aspart (novolog) (non-formulary) target glucose: 80-180 discharge medications: 1. ibuprofen 800 mg po q8h:prn pain 2. insulin pump sc (self administering medication)insulin aspart (novolog) (non-formulary) basal rate minimum: 0.7 units/hr target glucose: 80-180 3. levothyroxine sodium 75 mcg po daily 4. sertraline 50 mg po daily 5. acetaminophen 1000 mg po q8h:prn pain discharge disposition: home discharge diagnosis: primary diagnosis: - diabetic ketoacidosis secondary diagnoses: - diabetes type 1 - hashimotos thyroiditis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. [**last name (titles) 6129**], you came into the ed because of nausea, vomiting, hyperglycemia, and were found to be in diabetic ketoacidosis (dka). you were admitted to the icu because you were required an insulin drip. you were also given several liters of fluid and your blood sugars came back down to normal. we monitored you overnight and your symptoms resolved and your sugars were controlled with your home insulin pump. you were also complaining of shoulder pain from your right rotator cuff and you are scheduled for follow up with ortho to have a cortisone injection. you should not take tramadol any longer due to the adverse reaction of nausea and vomiting which may have caused you to go into dka. it was a pleasure taking care of you at the [**hospital1 18**]! followup instructions: you have the following appoinments scheduled following discharge: name: [**first name8 (namepattern2) **] [**last name (namepattern1) 3640**], np location: [**last name (un) **] diabetes center address: one [**last name (un) **] place, [**location (un) **],[**numeric identifier 718**] phone: [**telephone/fax (1) 3402**] appt: thursday, [**10-12**] at 10:30am note: this appointment is with a member of dr [**last name (stitle) 43475**] team as part of your transition from the hospital back to your primary care provider. [**name10 (nameis) 616**] this visit, you will see your regular provider. department: orthopedics when: monday [**2175-10-23**] at 10:00 am 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: spine center when: monday [**2175-10-23**] at 10:20 am with: [**first name4 (namepattern1) 1141**] [**last name (namepattern1) 4983**], np [**telephone/fax (1) 8603**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) 551**] campus: east best parking: [**hospital ward name 23**] garage department: [**hospital3 249**] when: monday [**2175-11-13**] at 3:45 pm with: [**name6 (md) **] [**name8 (md) 10918**], md [**telephone/fax (1) 2010**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) 895**] central [**hospital **] campus: east best parking: [**hospital ward name 23**] garage note: dr [**last name (stitle) **] is a resident and your new physician in [**name9 (pre) 191**]. dr [**first name4 (namepattern1) **] [**last name (namepattern1) 43476**] over sees this doctor and both will be involved in your care. for insurance purposes, dr [**first name4 (namepattern1) **] [**last name (namepattern1) **] [**doctor last name **] will be listed as your pcp in your record. completed by:[**2175-10-9**]",1
49,"admission date: [**2156-4-13**] discharge date: [**2156-4-14**] date of birth: [**2083-10-18**] sex: m service: medicine allergies: ceftriaxone attending:[**first name3 (lf) 8404**] chief complaint: [**first name3 (lf) **] meningitis, ceftriaxone desensitization major surgical or invasive procedure: picc line history of present illness: 72-year-old male with history of [**first name3 (lf) **] disease ([**2149**] and [**2154**]) and glaucoma who developed bell's palsy after a trip to [**hospital3 **] two weeks ago presents to the [**hospital3 12145**] for ceftriaxone desensitization for presumed [**hospital3 **] meningitis. . his symptoms started on [**2156-3-29**] when he developed a left sided headache. he also had low-grade fever of 100.5 around this time. he saw dr. [**first name8 (namepattern2) 1158**] [**last name (namepattern1) 679**] on [**2156-4-1**] who ordered an mri head, which came back negative. his symptoms continued to worsen and he developed left sided numbness and difficulty closing his left eye. he was concerned for closed angle glaucoma, which he has a history of and presented to [**hospital 13128**], where he was ruled out for this and told to see an opthalmologist for the difficulty closing his left eye. he continued to worsen and was seen in the ed on [**4-4**] and blood taken in the ed returned positive for [**month/year (2) **]. he was seen by neurology who thought that he should be discharged with prednisone and seen by neuro urgent care. they decided not to take the prednisone because his wife read on the internet that you are not supposed to take steroids during an infection. he was referred to a neurologist who saw him yesterday on [**2156-4-12**] and did an lp which showed 53 wbc in 4th bottle, 94% lymphs (2rbc, protein 50, glucose 59) and was sent for vzv, hsv and borriella pcr which are pending. given his clinical course and lab results he was presumed to have [**date range **] meningitis requiring ceftriaxone. however, he has a hisory of rash immediately following ceftriaxone in the past so he is being directly admitted to the icu for ceftriaxone desensitization. . on arrival, the patient complains of mild left sided headache with retroorbital pain, which is the same as his prior pain for the past 2 weeks. he denies any other symptoms including chest pain, shortness of breath, cough, chills, sweats, nausea, vomitting, diarrhea, abdominal pain, calf pain, focal weakness, numbness or tingling, seizures, or any other neurologic symptoms. positive neck soreness but no stiffness. past medical history: #. hyperlipidemia, diet controlled. #. ventricular ectopy on stress test. #. history of glaucoma, controlled. #. lipoma removed left hip #. [**date range **] disease twice ([**2145**], [**2149**] both treated with doxycycline. in [**2154**] he had a tick bite and was treated with 1 dose of doxycycline) social history: retired editor of a sailing magazine. never smoker and drinks [**12-21**] glasses of wine weekly. no drugs. lives with his wife in [**location (un) 2030**] and exercises 3-4 times per week. family history: father: cva age 38 lived till 93, mother cva age 76 lived to 84. brother: melanoma and cad physical exam: gen: pleasant, comfortable, nad, obvious left sided facial droop heent: perrla, eomi, anicteric, mmm, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules resp: cta b/l with good air movement throughout cv: rr, s1 and s2 wnl, no m/r/g abd: nd, +b/s, soft, nt, no masses or hepatosplenomegaly ext: no c/c/e skin: no rashes/no jaundice/no splinters neuro: aaox3. cn ii-xii intact except for complete left sided facial droop with inability to close left eye lid, left sided facial numbness in all 3 dermatomes, an inability to smile with left side of face. 5/5 strength throughout upper and lower extremities. no sensory deficits to light touch appreciated. no pass-pointing on finger to nose. 2+dtr's-patellar and biceps. no nuchal rigidity. pertinent results: labs on admission: [**2156-4-13**] 03:58pm blood wbc-4.7 rbc-4.40* hgb-14.5 hct-41.2 mcv-94 mch-33.0* mchc-35.2* rdw-12.6 plt ct-233 [**2156-4-13**] 03:58pm blood neuts-67.9 lymphs-25.9 monos-4.1 eos-1.6 baso-0.5 [**2156-4-13**] 03:58pm blood plt ct-233 [**2156-4-13**] 03:58pm blood glucose-95 urean-15 creat-1.0 na-140 k-4.3 cl-104 hco3-28 angap-12 [**2156-4-13**] 03:58pm blood calcium-8.9 phos-3.1 mg-2.2 [**2156-4-12**] 03:40pm cerebrospinal fluid ([**month/day/year **]) protein-50* glucose-59 [**2156-4-12**] 03:40pm cerebrospinal fluid ([**month/day/year **]) wbc-53 rbc-2* polys-0 lymphs-94 monos-6 [**2156-4-12**] 03:40pm cerebrospinal fluid ([**month/day/year **]) wbc-44 rbc-7* polys-0 lymphs-94 monos-6 . labs on discharge: [**2156-4-14**] 03:26am blood wbc-4.5 rbc-4.17* hgb-13.5* hct-38.6* mcv-93 mch-32.4* mchc-35.0 rdw-12.7 plt ct-217 [**2156-4-14**] 03:26am blood glucose-118* urean-12 creat-0.9 na-139 k-3.9 cl-107 hco3-26 angap-10 . pending labs: - to follow up [**month/day/year **] [**month/day/year **] igm/igg results call [**company 5620**] at [**telephone/fax (1) 40616**] - to follow up blood [**telephone/fax (1) **] igm/igg results call [**hospital **] medical labs at [**telephone/fax (1) 40617**], be sure to have [**hospital1 18**] account # if necessary ([**numeric identifier 40618**]) brief hospital course: 72-year-old male with history of [**numeric identifier **] disease ([**2149**] and [**2154**]) and glaucoma who developed bell's palsy after a trip to [**location (un) 7453**] two weeks ago presents to the [**location (un) 12145**] for ceftriaxone desensitization for presumed [**location (un) **] meningitis. . #. subacute meningitis: presumed [**location (un) **] meningitis given recent exposure, positive [**location (un) **], bell's palsy and [**location (un) **] done as an outpatient with normal glucose, lymphocytic predominence, and negative gram stain. patient's pcp arranged for him to be admitted to the hospital for ceftriaxone desensitizaton given his history of immediate allergy to ceftriaxone. hsv encephalitis is unlikely given the lack of confusion or altered mental status and lack of associated changes on recent mri brain imaging. hsv titer is pending. plan was discussed with infectious disease, neurology (dr. [**last name (stitle) **], pcp, [**name10 (nameis) 12145**], and allergy attendings on call. -patient tolerated ceftriaxone desensitization on [**4-13**] -he received his first dose of ceftriaxone 2 grams on [**4-14**] -per discussion with neurology (dr. [**last name (stitle) **], will proceed with 2 gram iv ceftriaxone for 28 days -picc line was placed on [**4-14**] for 28 days of abx -hsv, vzv, [**month/year (2) **] culture, [**month/year (2) **] igm and igg serologies, and b.burgdorferi pcr in [**month/year (2) **] are pending and will be followed by pcp, [**name10 (nameis) **] [**last name (stitle) 1007**] . #. ceftriaxone allergy: -ceftriaxone desensitization per protocol completed without adverse reaction . #. hyperlipidemia -diet controlled -fish oil as an outpatient . f/u on discharge: - routine picc line care - ceftriaxone 2 gram iv x 28 days with pcp [**first name4 (namepattern1) **] [**last name (namepattern1) 1007**] - hsv, vzv, [**last name (namepattern1) **] culture, [**last name (namepattern1) **] igm and igg serologies, and b.burgdorferi pcr in [**last name (namepattern1) **] are pending and will be followed by pcp [**name initial (pre) **] [**name10 (nameis) **] [**name11 (nameis) **] igm/igg results [call [**company 5620**] at [**telephone/fax (1) 40616**]] - [**telephone/fax (1) **] igm/igg results [call [**hospital **] medical labs at [**telephone/fax (1) 40617**], be sure to have [**hospital1 18**] account # if necessary ([**numeric identifier 40618**])] medications on admission: 1) aspirin 81 mg 2) fish oil discharge medications: 1. ceftriaxone 2 gram recon soln sig: two (2) grams intravenous once a day for 28 days. 2. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 3. fish oil 1,000 mg capsule sig: one (1) capsule po once a day. capsule(s) discharge disposition: home discharge diagnosis: primary: 1. [**numeric identifier **] meningitis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you came to the hospital because you have [**numeric identifier **] meningitis and you needed ceftriaxone desensitization. you tolerated this well. it is very important that you continue to take your ceftriaxone on time every day or else you are at risk of an allergic reaction. it is also important to know that once your course of antbiotics is finished you will still be allergic to ceftriazone. if you need this medication again you will have to come to the hospital again. . we made the following changes to your medications: ceftriaxone 2g iv q24 hours for 28 days please continue to take all your medications as tolerated. followup instructions: you will follow-up with neurology, dr. [**first name8 (namepattern2) 5464**] [**last name (namepattern1) **], on [**5-21**] at 11:30 am. if there are any concerns, please call her at [**telephone/fax (1) 31415**]. . dr. [**first name4 (namepattern1) **] [**last name (namepattern1) 1007**], your pcp, [**name10 (nameis) **] arrange for you to come in to his office for daily iv antibiotics and weekly blood tests during the four weeks of ceftriaxone. [**name6 (md) **] [**name8 (md) **] md [**md number(2) 8405**]",0
50,"admission date: [**2118-4-12**] discharge date: [**2118-4-16**] date of birth: [**2058-6-24**] sex: f service: [**company 191**] chief complaint: the patient was admitted originally for airway monitoring status post endoscopic retrograde cholangiopancreatography with adverse reaction to fentanyl and tongue injury. history of present illness: the patient is a 59 year-old female status post endoscopic retrograde cholangiopancreatography on the day of admission, which had been done to evaluate for possible bile leak after cholecystectomy was performed four days ago. the patient was in her usual state of health until four days prior to admission when she had a cholecystectomy. her postop course was uneventful until one day prior to admission when she developed abdominal pain. she went to an outside hospital emergency room and was reassured and sent home. on the day of admission she returned to the outside hospital emergency room where an abdominal ct was performed, which showed ""thickened stomach and free air."" she was sent to [**hospital1 1444**] for an endoscopic retrograde cholangiopancreatography and possible stent placement. she had a successful endoscopic retrograde cholangiopancreatography, which showed a bile leak at the duct of luschka. a stent was placed successfully. after her endoscopic retrograde cholangiopancreatography the patient developed ""jaw clenching, biting tongue, rigidity and cold/chills."" the patient received ampicillin, gentamycin and flagyl empirically as well as narcan to reverse fentanyl. because of the tongue injury and tachycardia as well as possible infection given her fevers or chills the gi service transferred the patient to the micu for close observation. past medical history: 1. hiatal hernia. 2. status post cholecystectomy four days prior to admission. 3. urinary frequency secondary to interstitial cystitis. 4. mitral valve prolapse. 5. tubal ligation many years ago. medications on admission: 1. prempro. 2. eye drops. allergies: no known drug allergies at the time of admission, however, it is assumed that her rigidity and jaw clenching was secondary to fentanyl. social history: the patient is married. she works as a teacher's aid in [**location (un) 8072**]. she denies tobacco or alcohol use. physical examination on admission to the micu: vital signs temperature 100.6. heart rate 105. blood pressure 162/76. respiratory rate 18. sating 98% on 3 liters. in general, the patient was groggy status post anesthesia, shivering, but awake. heent showed tongue with laceration on the right edge. mucous membranes are moist. pupils are equal, round and reactive to light. extraocular movements intact. lungs were clear to auscultation bilaterally. heart regular rate and rhythm. no murmurs, rubs or gallops. abdomen was soft, nontender, nondistended. there were normoactive bowel sounds. there was no rebound or guarding. there were post laparoscopic incisions without erythema with steri-strips in place. the extremities were without edema. dorsalis pedis pulses were intact bilaterally. there were no rashes. laboratories on admission: white blood cell count 9.0, hematocrit 39.3, platelets 296, neutrophil count 82, lymphocytes 14, 4 monocytes, troponin was less then 0.3. sodium 139, potassium 3.8, chloride 101, bicarb 26, bun 9, creatinine 0.7, glucose 141, albumin 4.1, calcium 8.9, ldh 665, ast 44, alt of 57, amylase 41, ck 32. electrocardiogram showed normal sinus rhythm at 73 beats per minute. there was normal axis. normal intervals. there were no st or t wave changes. abdominal ct showed inflammation in the right upper quadrant, small fluid in the circumferential thickening of the distal stomach. there was a question of a small ulcer. there was a tiny amount of free air. this was per report of [**hospital3 3583**]. hospital course: in summary the patient is a 59 year-old female who was admitted to [**hospital1 188**] for an endoscopic retrograde cholangiopancreatography for possible stent placement for a bile leak secondary to cholecystectomy performed four days prior to admission. she then suffered rigidity with jaw clenching and tongue biting secondary to fentanyl administration and was transferred to the micu for close observation. she did well overnight in the micu. she was started on ampicillin, gentamycin and flagyl. her liver function tests and amylase and lipase were followed closely. on the second hospital day the patient was doing much better and was stable from an airway perspective, so she was transferred to the general medical floor. 1. gastrointestinal: as stated the patient was status post endoscopic retrograde cholangiopancreatography with stent placement for a bile leak from the duct of luschka. the patient was continued on ampicillin, gentamycin and flagyl, which had been started at the time of transfer to the micu. she had waxing and [**doctor last name 688**] fevers. however, her white blood cell count was never really elevated and she did not have a bandemia. on the day of transfer to the general medical floor the patient had received clear liquids. she did not tolerate this very well. her amylase and lipase on the day following the endoscopic retrograde cholangiopancreatography were elevated. amylase was 2304 with lipase being 7116. therefore she was made npo and given aggressive intravenous hydration. on the second hospital day on the general medical floor the patient had marked rebound to palpation of her abdomen. she was followed closely with serial abdominal examinations. her amylase and lipase were trending down, however. an abdominal ct was obtained, which showed only mild pancreatitis. there were no intra-abdominal fluid collections, which required any drainage. on the third hospital day the patient's pain was improving and the rebound was decreasing. her enzymes continued to trend down. she received clear liquids in the evening and tolerated these well. on the day of discharge the patient was tolerating a brat diet without significant abdominal pain. she had no further rebound. she had no temperature spikes in greater then 24 hours at the time of discharge. 2. hematology: the patient's hematocrit was 34.8 at the time of admission. it decreased to 30 in the setting of aggressive hydration. it remained stable at the time of discharge and it was 29.5 on the day of discharge. 3. fen: the patient was aggressively hydrated given that she was npo. she required periodic repletion of her potassium. her bicarb began to drop and she developed an anion gap acidosis. this was most likely secondary to ketoacidosis as she had no dextrose in her intravenous fluids. this was added on the evening prior to discharge and on the day of discharge her anion gap acidosis had resolved. condition on discharge: stable. medications on discharge: 1. levaquin 500 mg one po q day times seven days. 2. protonix 40 mg po q day. 3. percocet one to two tablets po q 4 to 6 hours prn. the patient was given a prescription for ten pills. 4. prempro as the patient was formerly taking. 5. trazodone at bedtime. discharge follow up: the patient was to make an appointment with dr. [**last name (stitle) **] within one to two months after discharge for removal of the stent. in addition, she would follow up with her primary care physician within one to two weeks following discharge. she was to continue on a brat diet over the weekend and two days after discharge she could advance to a low fat no dairy diet. she could slowly advance back to a normal diet over the next week. discharge diagnoses: 1. post endoscopic retrograde cholangiopancreatography pancreatitis. 2. anemia. 3. hypokalemia. 4. anion gap acidosis. 5. bile leak. [**doctor last name **] [**name6 (md) **] [**name8 (md) **], m.d. [**md number(1) 5712**] dictated by:[**last name (namepattern1) 6859**] medquist36 d: [**2118-4-16**] 13:49 t: [**2118-4-18**] 08:16 job#: [**job number 35463**]",1
51,"admission date: [**2137-11-13**] discharge date: [**2137-11-20**] date of birth: [**2070-3-25**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**first name3 (lf) 14820**] chief complaint: acute dyspnea major surgical or invasive procedure: none history of present illness: 67 yo m with dm2, htn, and recent dx of a-fib 1 month ago presents with acute dyspnea and found to be in afib with rvr. the patient recently started taking diltiazem and coumadin 3 weeks ago. he was feeling well until he acutely felt short of breath yesterday morning. he presented to his pcp's office where an ekg was significant for afib with rvr in the 140s. he was then sent to [**hospital3 **] for further evaluation. cxr revealed pulmonary edema and fluid overload. he was started on a hep gtt for a sub-therapeutic inr, diltiazem gtt, nitro gtt, and transferred to [**hospital1 18**] for further care. . in the ed, initial vitals bp 96/68 hr 107. he was given 80 then 160 mg iv lasix with approximately 1l urine output. in spite of a diltiazem gtt, his hr remained in the 110s. a repeat cxr showed small bilateral pleural effusions and mild pulmonary edema. labs were significant for a troponin leak up to 0.66 with flat cks, bnp [**numeric identifier 39390**], inr 1.5, and cr 1.7. while in the ed overnight, he desatted down to low 80s and was placed on bipap and then a nrb with sats improving to >94%. he was unable to be weaned off the nrb in spite of putting out approximately 1 l urine to iv lasix. due to continued tachycardia, respiratory distress, and ? hemodynamic instability, the pt was taken for tee/cardioversion. tee revealed a left atrium thrombus. he was then admitted to the ccu for further care. . 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 reports having calf pain on exertion and is on cilastazol for peripheral arterial disease. he also reports have 2 incidents of hypoglycemia in the past month; his beta-blocker was stopped and he was started on a ccb. all of the other review of systems were negative. . cardiac review of systems is notable for dyspnea, but the absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope, or presyncope. past medical history: dm ii htn erectile dysfunction cardiac risk factors: diabetes, dyslipidemia, hypertension, former smoker social history: social history is significant for the absence of current tobacco use. he quit over 20 years ago. there is no history of alcohol abuse. family history: non-contributory physical exam: vs: t 98.3 , bp 132/72 , hr (112-126), rr 36 , o2 96% on nrb gen: elderly male, in moderate resp distress on nrb appears more comfortable, oriented x3. mood, affect appropriate. pleasant. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. neck: supple with jvp of [**12-20**] cm. cv: irregular, tachycardic; normal s1, s2. no s4, no s3. chest: resp were labored, with accessory muscle use. decreased bs bilateral bases with crackles halfway up posterior lung fields. few scattered expiratory wheezes abd: obese, soft, ntnd, no hsm or tenderness. ext: no c/c/e. skin: venous stasis changes bilateral lower extremities. pulses: right: carotid 2+; radial 2+; 1+ dp/pt [**name (ni) 2325**]: carotid 2+; radial; 2+; 1+ dp/pt pertinent results: [**2137-11-20**] 05:45am blood wbc-7.8 rbc-4.34* hgb-13.7* hct-39.8* mcv-92 mch-31.5 mchc-34.3 rdw-14.2 plt ct-335 [**2137-11-20**] 05:45am blood pt-17.3* ptt-90.2* inr(pt)-1.6* [**2137-11-20**] 05:45am blood glucose-101 urean-29* creat-1.3* na-138 k-4.1 cl-100 hco3-30 angap-12 [**2137-11-13**] 11:29pm blood ck(cpk)-51 [**2137-11-12**] 05:30pm blood ck(cpk)-135 [**2137-11-13**] 03:51pm blood ck-mb-notdone ctropnt-0.66* [**2137-11-12**] 05:30pm blood ck-mb-12* mb indx-8.9* probnp-[**numeric identifier 39390**]* [**2137-11-17**] 06:15am blood albumin-3.6 calcium-11.3* phos-4.2 mg-3.0* [**2137-11-18**] 05:35am blood digoxin-1.1 [**2137-11-16**] 09:00am urine color-straw appear-clear sp [**last name (un) **]-1.005 [**2137-11-16**] 09:00am urine blood-lge nitrite-neg protein-neg glucose-1000 ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-neg [**2137-11-16**] 09:00am urine rbc-11* wbc-2 bacteri-none yeast-none epi-0 . imaging: . [**2137-11-12**] cxr impression: cardiomegaly with bilateral small pleural effusions and mild pulmonary edema . [**2137-11-14**] cxr findings: in comparison with the study of [**11-12**], there is continued cardiomegaly with apparent worsening of the pulmonary edema. generalized haziness bilaterally is consistent with large pleural effusions . [**2137-11-15**] cxr there is marked improvement in the bilateral perihilar parenchymal opacities representing marked improvement of pulmonary edema. there is no change in bilateral moderate pleural effusions and bibasal atelectasis. the moderately enlarged heart is stable and there is no change in the mediastinal contours. . [**2137-11-17**] cxr: previous pulmonary edema and bilateral pleural effusions have resolved. mild cardiomegaly and upper lobe vascular congestion remain following substantial improvement in congestive heart failure. no pneumothorax. . [**2137-11-13**] tee: the left atrium is dilated. no spontaneous echo contrast or thrombus/ mass is seen in the body of the left atrium. mild spontaneous echo contrast is present in the left atrial appendage. the left atrial appendage emptying velocity is depressed (<0.2m/s). a probable thrombus is seen in the left atrial appendage. no spontaneous echo contrast is seen in the body of the right atrium. mild spontaneous echo contrast is seen in the right atrial appendage. the right atrial appendage ejection velocity is depressed (<0.2m/s). no thrombus is seen in the right atrial appendage no atrial septal defect is seen by 2d or color doppler. lv systolic function and right ventricular systolic function appears depressed. there are simple atheroma in the aortic arch and descending thoracic aorta. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. there is no aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen (severity of mitral regurgitation may be underestimated due to limited views). there is no pericardial effusion. . impression: probable left atrial appendage thrombus. moderate mitral regurgitation (may be underestimated). biventricular systolic dysfunction. . [**2137-11-18**] tte: the left atrium is mildly dilated. no left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). the estimated right atrial pressure is 0-10mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size. overall left ventricular systolic function is low normal (lvef 50%). right ventricular chamber size and free wall motion are normal. there is abnormal septal motion/position. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are moderately thickened with characteristic rheumatic deformity/restricted anterior and posterior leaflet motion.. there is a minimally increased gradient consistent with trivial mitral stenosis. mild to moderate ([**1-8**]+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. . impression: minimal rheumatic mitral stenosis. mild-moderate mitral regurgitation. low normal left ventricular systolic function mild pulmonary artery systolic hypertension. . [**2137-11-12**] ecg: atrial fibrillation, average ventricular rate 100-110. non-specific repolarization changes. compared to the previous tracing of [**2135-3-21**] normal sinus rhythm has given way to atrial fibrillation and the ventricular rate has increased. . [**2137-11-16**] ecg: atrial fibrillation with rapid ventricular response left ventricular hypertrophy diffuse nonspecific st-t wave abnormalities since previous tracing of [**2137-11-15**], further st-t wave changes present brief hospital course: 67 yo male with afib diagnosed 1 month ago presents with afib with rvr and hypervolemia admitted for cardioversion but found to have left atrial appendage thrombus on tee, admitted to ccu for monitoring and diuresis. . # rhythym: afib with rvr. unable to cardiovert due to [**name prefix (prefixes) **] [**last name (prefixes) 1916**] thrombus on tee. the patient was initially started on digoxin and a diltiazem gtt for rate control. the diltiazem was converted to a po dosing regimen which the patient tolerated well. his hr continued to be slightly fast, therefore low dose metoprolol was started. as an outpatient, the patient had been on high doses of toprol likely causing his adverse reactions and no response to hypoglycemia, but the patient's glucose was well controlled during his hospitalization and he tolerated the metoprolol dosing well. the patient was started on a heparin gtt, and was bridge to coumadin with lovenox as an outpatient. his goal inr is [**2-9**] and will need to be followed by his pcp. [**name10 (nameis) **] will followup in cardiology clinic for his a.fib. he will need a repeat tee in [**4-12**] weeks to determine resolution of the left atrial appendage thrombus if he will have cardioversion. . # pump: chf with ef of 43% at osh. tee not able to accurately determine ef. a tte prior to discharge showed an ef of 50%. the patient was diuresed with iv lasix initially, but was then converted to a po dosing schedule to further keep him even to slightly negative as an outpatient. . # ischemia: elevated troponin likely from demand ischemia in setting of afib with rvr. the patient did not have cardiac catheterization during this hospitalization. he will likely need an outpatient stress test or catheterization based on the decision of his cardiologist. the patient did not complain of chestpain throughout this hospitalization. he will continue on aspirin, statin, and metoprolol as an outpatient. . # htn-the patient's blood pressure was well controlled on his regimen of diltiazem, metoprolol, and lisinopril. he will continue these medications as an outpatient. . # dm: the patient initially had blood glucose levels in the 400s. his nph and hiss were up-titrated for improved control. prior to discharge, the patient was on nph 30/14 with a tight hiss with good glucose control 120-150s. he has a long history with dr. [**last name (stitle) 19862**] at the [**last name (un) **] who follows him as an outpatient. dr. [**last name (stitle) 19862**] was informed of the patient's admission, and the patient will followup at the [**last name (un) **] with his scheduled appointments. medications on admission: lasix 40 mg daily lipitor 20 mg daily cardia 180 mg qam cilastazole 100 mg [**hospital1 **] warfarin 2.5 mg qhs discharge medications: 1. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 3. digoxin 250 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 6. warfarin 2 mg tablet sig: two (2) tablet po daily16 (once daily at 16). disp:*60 tablet(s)* refills:*0* 7. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*30 tablet(s)* refills:*2* 8. diltiazem hcl 240 mg capsule, sustained release sig: one (1) capsule, sustained release po bid (2 times a day). disp:*60 capsule, sustained release(s)* refills:*2* 9. insulin nph human recomb 100 unit/ml suspension sig: as directed units subcutaneous twice a day: 30 units at breakfast, 14 units at dinner. disp:*qs units* refills:*2* 10. insulin regular human 100 unit/ml solution sig: as directed units injection four times a day: per home sliding scale. 11. enoxaparin 80 mg/0.8 ml syringe sig: eighty (80) units subcutaneous twice a day for 2 weeks: please continue until inr [**2-9**]. . disp:*qs syringe* refills:*1* discharge disposition: home with service facility: [**location (un) 86**] vna discharge diagnosis: primary diagnosis: atrial fibrillation with rapid ventricular rate secondary diagnosis: pulmonary edema hypertension discharge condition: stable, off o2 discharge instructions: you were admitted for atrial fibrillation with a rapid heart rate and fluid overload, predominantly in your lungs. you were started on medications to slow down your heart rate, and you were also given medication to decrease the fluid in your body. initially, you required oxygen via a mask at admission, but by the time of discharge, you were off of oxygen and were able to walk around without difficulty. please take all medications as prescribed. please make all appointments as scheduled. vna services will teach you how to administer lovenox until your inr is therapeutic. they will also check your inr and adjust accordingly with the help of dr. [**last name (stitle) 18323**]. when vna no longer come visit please go back to coming to the hospital as previously for your inr checks. followup instructions: provider: [**first name11 (name pattern1) **] [**last name (namepattern4) **], m.d. phone:[**telephone/fax (1) 4023**] date/time:[**2137-12-4**] 1:40 please schedule an appointment with your pcp to be seen within 1-2 weeks",1
52,"admission date: [**2105-11-22**] discharge date: [**2105-11-25**] service: ccu chief complaint: inferior st-elevation myocardial infarction. history of present illness: the patient is a 78-year-old male with no prior cardiac history who described atypical neck and arm pain over the preceding two to three months prior to admission while playing golf. he had been told by his orthopaedic surgeon that he had arthritis; however, the character of the pain changed over the past two weeks to include substernal pressure and pain with exertion which was relieved with rest. he presented to [**hospital3 **] twice over the past two weeks. he had electrocardiograms done, enzymes, and chest x-rays and told that his pain was likely not cardiac. his primary care physician thought that his pain was musculoskeletal and prescribed ibuprofen. on the night prior to admission, at around 11 p.m., the patient experienced sudden [**9-1**] to [**10-1**] substernal chest pain radiating to the arms and neck. not associated with any nausea, vomiting, or diaphoresis. he went to [**hospital3 38285**] where electrocardiogram showed initially 1-mm st elevations in ii, ii, and avf and st depressions in v1 through v3. he was given sublingual nitroglycerin times three, morphine, and given 10 units of retavase times two (30 minutes apart). subsequent electrocardiograms showed worsening st elevations up to 2 mm to 3 mm inferiorly with reciprocal 3-mm to 4-mm st depressions in v1 through v4. the patient was started in a heparin drip and was pain free at the time of transfer to [**hospital1 69**]. past medical history: 1. hypertension. 2. anxiety/panic attacks. 3. hiatal hernia. 4. irritable bowel syndrome. 5. gastroesophageal reflux disease. 6. glaucoma. allergies: tetracycline (causes swelling of the tongue) and timoptic and other beta blocker medications (which have led to respiratory difficulty). medications on admission: 1. ibuprofen p.o. as needed. 2. bentyl. 3. librium 10 mg p.o. q.d. as needed. 4. rescula eyedrops one drop both eyes b.i.d. 5. cardizem-cd 240 mg p.o. q.d. 6. zantac 150 mg p.o. b.i.d. 7. aspirin 81 mg p.o. q.d. 8. glucosamine chondroitin. 9. multivitamin. medications on transfer: additional medications at the time of transfer included nitroglycerin drip and a heparin drip. social history: the patient has about a 30-pack-year smoking history, though he quit in [**2062**]. currently, he smokes approximately two cigars per day (which he quit this winter). he drinks alcohol only occasionally. he used to work as a motion picture projectionist. he is now retired and works at a golf course. physical examination on presentation: physical examination on admission revealed he was a very pleasant, in no acute distress. he had no jugular venous distention. his lung was clear to auscultation bilaterally. his heart examination had a normal first heart sound and second heart sound without murmurs, gallops, or rubs. he had no peripheral edema and 2+ dorsalis pedis pulses. radiology/imaging: electrocardiogram on admission to the coronary care unit showed a sinus rhythm at 90 beats per minute with a leftward axis. normal intervals and upward cove st segments inferiorly with resolution of the st elevations and only slight residual st depressions in v3 and v4. pertinent laboratory data on presentation: laboratories on admission were remarkable for a creatine kinase of 2768 with a mb fraction of 158. laboratories from the outside hospital showed a mb of 7.9 and a troponin of 5.1. complete blood count and chemistry-10 were all within normal limits. coagulations revealed ptt was 100.8. hospital course: 1. cardiovascular system: (a) coronary artery disease: as the patient was pain free on admission to the coronary care unit, there was no indication for emergent catheterization. he was continued on aspirin, heparin drip, and a nitroglycerin drip. because of the patient's adverse reaction in the past to beta blockers, there was concern in initiating this medication. the patient was initially given a test dose of esmolol at 50 mcg/kg per minute to control his heart rate which was elevated in the 90s. the patient tolerated the esmolol very well, and the following morning was changed to oral lopressor at 12.5 mg b.i.d. on the morning of admission, the patient was also loaded on plavix at 300 mg with the dose then changed to 75 mg p.o. q.d. thereafter. he was also started on integrilin that evening in preparation for a catheterization the next day. his creatine kinases were cycled and showed that his peak creatine kinase was 2768; the value on admission. on [**2105-11-23**], the patient was taken to the cardiac catheterization laboratory. coronary angiography revealed a right-dominant system. there was a 90% proximal left circumflex stenosis, 70% medial left circumflex stenosis, and 70% first obtuse marginal stenosis. there was also a long 80% medial right coronary artery lesion. the proximal circumflex lesion was stented times two; the second stent being placed distally because of dissection. the distal circumflex stent was stented as well as was the medial right coronary artery stenosis. the patient tolerated the procedure well, and after the catheterization laboratory went to the general medicine floor. his beta blocker had been titrated up to a dose as high as 50 mg p.o. b.i.d., at which time the patient began to develop some respiratory complaints including shortness of breath, the feeling of tightness in his chest, and a cough. his lopressor was held initially, and the beta blocking effects were reversed with an albuterol inhaler; to which the patient responded to very well; however, his cough persisted. due to the possibility that his cough could have been induced by captopril which the patient had been started on, captopril was stopped, and he was changed to an angiotensin receptor blocker (cozaar) on which he was to be discharged. (b) pump: the patient was started initially on captopril and titrated as his blood pressure allowed. because his blood pressures remained in the 80s to 90s systolic, he was continued on only 6.25 mg p.o. t.i.d. as stated above, because of the cough, the patient's captopril was stopped and he was changed to cozaar on the day of discharge. (c) rhythm: as the patient did not tolerate a beta blocker, it was discontinued. the patient was to be restarted on his outpatient dose of cardizem 240 mg p.o. q.d. he was in sinus rhythm throughout his admission. 2. pulmonary system: on hospital day three, the patient developed respiratory complaints thought to be due to his beta blocker medications (as stated above). the beta blocker was reversed with an albuterol inhaler, to which he responded to very well, and his symptoms resolved short of a mild dry cough; felt likely to be due to the captopril. 3. anxiety: the patient was treated with librium as needed. discharge status: the patient was discharged to home. following a physical therapy evaluation, he was deemed safe to return home. medications on discharge: 1. cozaar 25 mg p.o. q.d. 2. aspirin 325 mg p.o. q.d. 3. plavix 75 mg p.o. q.d. 4. cardizem-cd 240 mg p.o. q.d. 5. rescula eyedrops one drop both eyes b.i.d. 6. zantac 150 mg p.o. b.i.d. 7. librium 10 mg p.o. q.d. as needed (for anxiety). 8. ibuprofen p.o. as needed. 9. bentyl p.o. as needed 10. glucosamine chondroitin (as taken prior to admission). discharge diagnoses: acute myocardial infarction. discharge instructions/followup: the patient was to follow up with his primary care physician (dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **]) in one to two weeks following discharge. [**first name11 (name pattern1) **] [**last name (namepattern4) **], m.d. [**md number(1) 8227**] dictated by:[**name8 (md) 3491**] medquist36 d: [**2105-11-25**] 12:06 t: [**2105-11-27**] 10:02 job#: [**job number 39874**]",1
53,"admission date: [**2161-5-6**] discharge date: [**2161-5-12**] date of birth: [**2107-6-10**] sex: f service: medicine allergies: demerol attending:[**first name3 (lf) 30**] chief complaint: torn medial meniscus shortness of breath bronchospasm major surgical or invasive procedure: medial meniscus repair. intubation and mechanical ventilation. central venous line placement. history of present illness: ms. [**known firstname 17937**] [**known lastname 6633**] is a 53 yo female with pmhx of asthma, colon cancer s/p resection, htn, osteoarthritis who was admitted for elective r knee arthroscopy [**2161-5-6**]. ms. [**known lastname 6633**] [**last name (titles) 1834**] r knee arthroscopy, with repeat partial posterior [**doctor last name 534**] medial meniscectomy, partial lateral meniscectomy. although she appeared to tolerate her surgery well, her immediate post-op course was complicated by diffuse wheeze and hypercarbic respiratory failure of unclear etiology (?bronchospastic adverse durg reaction) shortly after the lma was removed, necessitating intubation. she had received 1l of crystalloid, decadron 10 mg and albuterol mdi x2 in the or. medications administerd in the pacu included ketoralac, albuterol nebulizers, racemic epi neb, terbutaline 0.5 sc, lidocaine iv, ketamine, propofol peri-intubation. her pre-intubation abg revealed: 7.26/59/113. of note, her post-intubation chest film did not reveal any infiltrates. . ms. [**known lastname 6633**] has recured micu care from [**5-6**] - [**5-11**]. her micu course was notable for several complications, as follows. . 1) respiratory failure. she was maintained on empiric steroids, initially prednisone -> methylprednisolone, and then transitioned back to prednisone [**5-11**], as well as frequent nebs and inhaled steroids. she was successfully extubated [**5-8**] and has demonstrated improved respiratory status. . 2) she was noted to have a lactic acidosis, with lactate up to 11 [**5-6**], perhaps secondary to adverse reaction to propofol versus ?albuterol. her propofol was dicontinued, and switched to fentanyl/versed for sedation, and albuterol was also held. her lactate rapidly returned to baseline by [**5-7**]. . 3) she complained of l-sided cp, and was noted to have t wave flattening in the lat leads. she was given asa, started on captopril, and was briefly on a nitroglycerin drip, later transitioned to isosorbide dinitrate. serial cardiac enzymes were negative. an echo revealed an ef of 65%, with nl lv thickness and wall motion, and [**1-25**]+ mr. . 4) ?gib - after placement of an ng tube shortly after admission, she was noted to have ?coffee grounds. a lavage cleared shortly after infusion of saline. gi was consulted, who felt that her coffee grounds may have been secondary to stress gastritis in the setting of high-dose steroids, and she was begun on frequent ppi. her hct has remained stable. . 5) htn - patient has been noted to have significant htn, with sbps in the low 200s associated with mild ha. it is not clear what her pre-admission bp regimen was, though outpatient notes indicate lisinopril alone (?dose). she was begun on captopril -> lisinopril 20mg, hctz 25, and metoprolol, with improved control. a renal aretry u/s was obtained today for workup of ?secondary htn. past medical history: asthma htn knee oa s/p r knee arthroscopy in [**10-27**] obesity colon resection social history: [**date range 8003**]-speaking only. lives 1 hour from [**location (un) 86**] in a 2 floor home. eight children no tobacco no alcohol no illicit drug use. unable to exercise. physical [**location (un) **]: gen: patient appears stated age, found sitting up in bed, in nad heent: sclera anicteric, conjunctiva uninjected, perl, eomi, mmm, no sores in op, no evidence of thrush neck: no jvd, no lad, nl rom cor: rrr nl s1 s2 ii/vi hsm at apex chest: inspiratory, bibasilar crackles r>l. abd: soft, obese, nt/nd, +bs. no hsm appreciated. ext: no calf tenderness. no edema. 2+dp/pt pulses. r knee sutures intact, and knee is without evidence of inflammation (no fluctuance, warmth, or tenderness to palpation) neuro: ms [**first name (titles) **] [**last name (titles) **], cn ii-xii in tact, ue/le strength 5+ bilaterally, nl cerebellar [**last name (titles) **]. gait not tested. pertinent results: [**2161-5-6**] 03:05pm glucose-170* na+-143 k+-3.7 cl--103 tco2-28 [**2161-5-6**] 03:05pm o2-40 po2-113* pco2-59* ph-7.26* total co2-28 base xs--1 intubated-not intuba comments-cool neb [**2161-5-6**] 04:09pm type-art rates-[**4-4**] tidal vol-500 po2-424* pco2-71* ph-7.21* total co2-30 base xs--1 intubated-intubated [**2161-5-6**] 04:48pm pt-13.1 ptt-23.7 inr(pt)-1.1 [**2161-5-6**] 04:48pm plt count-145* [**2161-5-6**] 04:48pm neuts-85.2* lymphs-13.4* monos-1.0* eos-0.2 basos-0.2 [**2161-5-6**] 04:48pm wbc-8.3 rbc-4.01* hgb-12.1 hct-35.2* mcv-88 mch-30.3 mchc-34.5 rdw-12.7 [**2161-5-6**] 04:48pm calcium-8.9 phosphate-3.5 magnesium-1.7 [**2161-5-6**] 05:25pm lactate-5.8* [**2161-5-6**] 08:53pm plt count-161 [**2161-5-6**] 08:24pm type-art po2-158* pco2-39 ph-7.27* total co2-19* base xs--8 [**2161-5-6**] 08:53pm neuts-85* bands-6* lymphs-7* monos-2 eos-0 basos-0 atyps-0 metas-0 myelos-0 [**2161-5-6**] 08:53pm wbc-10.9 rbc-4.15* hgb-12.6 hct-36.7 mcv-88 mch-30.4 mchc-34.4 rdw-12.7 [**2161-5-6**] 08:53pm albumin-3.9 calcium-9.3 phosphate-2.5* magnesium-1.8 [**2161-5-6**] 08:53pm ck-mb-3 ctropnt-<0.01 [**2161-5-6**] 08:53pm alt(sgpt)-13 ast(sgot)-29 ld(ldh)-241 ck(cpk)-58 alk phos-100 amylase-88 tot bili-0.5 [**2161-5-6**] 08:57pm pt-13.6 ptt-24.5 inr(pt)-1.2 [**2161-5-6**] 09:00pm urine blood-neg nitrite-neg protein-neg glucose-1000 ketone-tr bilirubin-neg urobilngn-neg ph-5.0 leuk-neg [**2161-5-6**] 09:00pm urine color-yellow appear-clear sp [**last name (un) 155**]-1.020 [**2161-5-6**] 09:06pm lactate-11.2* [**2161-5-6**] 11:06pm lactate-10.3* k+-3.6 [**2161-5-6**] 09:06pm type-[**last name (un) **] [**2161-5-6**] 11:06pm type-art temp-35.6 rates-22/ tidal vol-500 peep-5 o2-40 po2-117* pco2-39 ph-7.31* total co2-21 base xs--6 intubated-intubated brief hospital course: 53 yo female with h/o asthma s/p elective r knee arthroscopy [**5-6**], who developed hypercarbic respiratory failure requiring intubation [**date range (1) 59224**], now recovering well on empiric steroids and nebulizers. . respiratory failure: likely [**2-25**] asthma flare possibly from instrumentation vs. adverse medication reaction vs. aspiration. continued to do well since being successfully extubated [**2161-5-8**]. received solumedrol taper and was converted to prednisone. -rapid prednisone taper -mdis -outpatient pulmonary workup, including pfts. . lactic acidosis: resolved on hospital day 2. felt to be either [**2-25**] propofol or less likely albuterol. . cp: currently chest pain free. prior lateral t wave flattening, ?etiology given serially negative cardiac enzymes. however, it is noteworthy that the cp occurred in the setting of coffee-ground emesis, and may actually have been gi in origin. -continue empiric asa. -bp control as below -consider d/c of empiric nitrates -recommend outpatient ett if has not been previously performed by outpatient cardiologist. . htn: managed by dr. [**last name (stitle) 35852**] ([**telephone/fax (1) 59225**]), affiliated with [**hospital1 2025**]). -continued lisinopril 20 mg daily -continued metoprolol, titrate dose (though given asthma flare, preferred to increase ace rather than b-blocker) -continued hctz . s/p arthroscopy: wound was healing well and eventually tolerated weight bearing with physical therapy. will need [**hospital1 **] follow-up and suture removal. . gastritis: suspect coffee grounds were secondary to stress gastritis as above. -continued pantoprazole. -outpaient egd . anemia: hct stably low with hct ~31. with normal iron and ferritin. suspect anemia of chronic dz. . hyperglycemia: steroid induced, continue riss . occult bacteremia: 1/4 bottles with staph epi. in culture [**5-10**] likely a contaminant. no intercurrent fevers or leukocytosis. . fen: maintained on cardiac diet . access: cvl (l subclavian). attempt piv, and then d/c cvl. . comm: [**name (ni) **], daughters, and [**name2 (ni) **] interpreter. daughter phone [**telephone/fax (1) 59226**]. . code: full. . dispo: patient was afebrile with stable vital signs on the day of discharge. she was not dyspneic and was able to speak in full sentences without distress. she had no further comnplaints and was able to bear weight on her knee s/p arthroscopy. she was without wheezing or rales on physical [**telephone/fax (1) **] and was euvolemic. she was discharged home in stable condition on a rapid prednisone rapid taper with pcp, [**name10 (nameis) **], and gi follow-up. . follow-up: with pcp for asthma management during rapid prednisone taper, management of anemia, and for exercise tolerance testing or pharmacological stress (as limited by asthma). with gi for outpatient egd for possible stress gastroenteritis). medications on admission: lisinopril flovent oxycodone albuterol prednisone x 5days in [**month (only) **] ultram discharge medications: 1. ipratropium bromide 18 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). disp:*1 inhaler* refills:*2* 2. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual asdir (as directed) as needed for pain: please let 1 tablet every 5 minutes for persistant chest pain. call your doctor if you need to take this medication. disp:*30 tablet, sublingual(s)* refills:*0* 3. albuterol 90 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours) as needed for wheeze. disp:*1 inhaler* refills:*0* 4. aluminum-magnesium hydroxide 225-200 mg/5 ml suspension sig: 15-30 mls po qid (4 times a day) as needed for indigestion. disp:*500 ml(s)* refills:*0* 5. aspirin 81 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 6. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 7. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). disp:*240 tablet(s)* refills:*2* 8. lisinopril 20 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 9. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 10. prednisone 10 mg tablet sig: see instructions below tablet po daily (daily): [**5-13**]: 3 tablets daily [**2079-5-13**]: 2 tablets daily [**date range (1) 59227**]: 1 tablet daily. disp:*12 tablet(s)* refills:*0* 11. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: [**1-25**] disk with devices inhalation [**hospital1 **] (2 times a day). disp:*1 disk with device(s)* refills:*2* 12. oxycodone hcl 5 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. disp:*20 tablet(s)* refills:*0* 13. toprol xl 50 mg tablet sustained release 24hr sig: three (3) tablet sustained release 24hr po once a day. disp:*90 tablet sustained release 24hr(s)* refills:*2* discharge disposition: home with service facility: [**hospital6 **] discharge diagnosis: torn medial meniscus, asthma flare, respiratory failure requiring intubation and mechanical ventilation discharge condition: stable. discharge instructions: please take prednisone as directed: on [**5-13**] take 30 mg (3 tablets) once each day. on [**2078-5-13**], and 23 take 20 mg (2 tablets) once each day. on [**2081-5-16**], and 26 take 10 mg (1 tablet) once each day. after [**5-19**], you are finished taking the prednisone. . please see dr. [**last name (stitle) **] to follow up about your knee on [**5-18**] at 10:50 am. . please take all the medications as listed by the prescriptions; you will be taking some new medications. . physical therapy will be assisting you at home. followup instructions: provider: [**first name11 (name pattern1) **] [**last name (namepattern4) 10486**], md where: [**hospital6 29**] orthopedics phone:[**telephone/fax (1) 1228**] date/time: [**2161-5-18**], 10:50",1
54,"admission date: [**2171-12-24**] discharge date: [**2172-1-8**] service: neurology allergies: patient recorded as having no known allergies to drugs attending:[**first name3 (lf) 618**] chief complaint: ""confusion"", transferred from osh with a diagnosis of intracranial hemorrhage major surgical or invasive procedure: picc line placement peg tube palcement history of present illness: this is a rh 84 year old woman with a past medical history significant for hypertension who presents with ""confusion"" and was found to have left occipital hemorrhage with intraventricular extension at [**hospital3 1443**] hospital, placed on nitro drip and transferred to [**hospital1 18**] for further managment. apparently she had c/o headache x 2-3 days prior to presentation per nephew. she was at home today and elder care services came as scheduled and found her confused and house in shambles. she was sent to osh ed where ct scan showed bleed. patient cannot recall or tell none of the event - she is awake/alert however and answering questions. she can follow simple commands if given slowly - but easily distracted, somewhat inattentive and perseverative. uti found at osh as well; given 400mg of ciprofloxacin. says she feels there is nothing wrong with her, though if specifically pressed on it, she admits she is ""not seeing well"" - though cannot describe why. past medical history: htn left knee replacement social history: lives alone, has elder care services, never married, no kids. has an elderly sister, [**name (ni) **], and nephew, [**name (ni) **] [**name (ni) 58812**] [**telephone/fax (1) 58813**]. family history: cad, dm, htn in multiple family members. sister alive and in her 90's. physical exam: physical exam: afebrile; bp 208/107; hr 60s; rr 18; o2 sat 100% o2 nc gen - no acute distress. appears comfortable. heent - mmm. o/p clear. no scleral icterus or injection. neck - supple. no lad or carotid bruits appreciated. lungs - cta bilaterally heart - rrr, nl s1/s2 abd - soft, nt/nd, nabs ext - warm, 2+ peripheral pulses throughout. no edema. neurologic: ms: alert and oriented x1 - knows she is in the hospital, but does not know which one. cannot tell me the date. cannot tell me anything of what happened today or yesterday. knows her age and birthdate. believes she is in hospital for ""stroke"" - but does not think she is having any current problems. refuses to attempt attention/memory testing. repitition intact. naming intact to high frequency objects. speech fluent with normal content and prosody, and without paraphasic errors or hesitancy. follows simple axial and appendicular commands - though is somewhat perseverative, difficult to change topics, and inattentive. cn: perrl. eoms intact without nystagmus. visual fields - right homonymous hemianopsia. facial sensation and movement intact bilaterally. tongue protrudes midline without fasiculations. sternocleidomastoids intact bilaterally. shoulder shrug intact bilaterally. motor: moves all extremities spontaneously and symmetrically. seems to be full strength in ues, but not attentive enough to follow formal strength commands in les - though is moving against gravity and some resistance bilaterally (at least [**2-18**]). reflexes: symmetric throughout. toes appear upgoing bilaterally. sensation: intact throughout to light touch, pinprick and cold. no extinction to dss. coordination: ftn intact bilaterally, does not follow instructions to perform tasks of ffm and [**doctor first name **] gait: deferred pertinent results: admission labs: [**2171-12-24**] 05:48pm blood wbc-13.3* rbc-4.24 hgb-12.6 hct-35.3* mcv-83 mch-29.7 mchc-35.8* rdw-13.4 plt ct-333 [**2171-12-24**] 05:48pm blood neuts-77.9* lymphs-16.8* monos-3.9 eos-1.1 baso-0.4 [**2171-12-24**] 05:48pm blood pt-12.6 ptt-24.3 inr(pt)-1.0 [**2171-12-24**] 05:48pm blood glucose-108* urean-20 creat-1.0 na-130* k-3.0* cl-94* hco3-27 angap-12 [**2171-12-24**] 05:48pm blood alt-10 ast-18 ld(ldh)-213 alkphos-65 totbili-0.5 [**2171-12-25**] 03:35pm blood lipase-27 [**2171-12-24**] 05:48pm blood ctropnt-0.01 [**2171-12-24**] 05:48pm blood calcium-8.5 phos-2.4* mg-1.5* [**2171-12-24**] 11:47pm blood phenyto-12.6 other labs: [**2171-12-25**] 03:35pm blood albumin-3.0* [**2171-12-25**] 03:35pm blood iron-183* caltibc-202* ferritn-124 trf-155* [**2171-12-25**] 03:53am blood vitb12-296 folate->20.0 [**2171-12-25**] 03:35pm blood cholest-160 triglyc-78 hdl-37 chol/hd-4.3 ldlcalc-107 [**2171-12-25**] 03:53am blood tsh-1.5 rpr -non-reactive microbiology: blood cultures [**2171-12-29**] pending urine culture [**2171-12-25**] no growth urine culture [**2171-12-29**] lactobacillus irome ci;tire [**2171-12-30**] pending nc head ct [**2171-12-25**]: area of intraparenchymal hemorrhage in the left occipital lobe, with likely extension into the left occipital [**doctor last name 534**], with some associated surrounding edema. as no prior studies are provided for comparison, determination of progression of this abnormality cannot be made. brain mri/mra [**2171-12-29**]: limited mri and mra of the brain due to motion. left occipital hemorrhage and right occipital and right cerebellar infarction. nc head ct [**2171-12-29**]: 1. new hypodensity within the right occipital lobe, which has progressed compared to the prior study of [**2171-12-25**], likely representing evolving infarction in the territory of the right pca. 2. stable appearance of intraparenchymal hemorrhage within the left occipital lobe, extending into the occipital [**doctor last name 534**] of the lateral ventricle. no interval increase in edema or mass effect, and no new areas of hemorrhage identified. cxr: there has been interval placement of a right picc line, with the tip overlying the distal svc. a nasogastric tube is seen within the esophagus, with the distal tube oriented cephalad above the left hemidiaphragm, apparently within a hiatal hernia. the heart and mediastinum are unchanged. once again, there is diffuse increased opacity of the right hemithorax, related to a layering right effusion. while the interstitial markings are prominent, there is no overt failure. echocardiogram [**2171-12-31**]: 1. the left atrium is moderately dilated. 2. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. left ventricular systolic function is hyperdynamic (ef>75%). 3. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis. trace aortic regurgitation is seen. 4. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. 5. there is mild pulmonary artery systolic hypertension. ct chest [**2172-1-2**]: 1) moderate-sized bilateral pleural effusion, associated with atelectasis. 2) no mass in the right upper lobe. 3) two noncalcified pulmonary nodules measuring 3 mm in diameter in the right upper lobe. please follow in one year if this patient has no history of malignancy, and please follow in three months if this patient has history of malignancy. 4) large hiatal hernia associated with 2-cm paraesophageal lymph node. 5) marked degenerative changes with compression fracture of the thoracic spine. brief hospital course: 1. left occipital bleed with intraventricular extension and right occipital infarction. 84 yo woman with history of hypertension who was transferred from the osh with left occipital bleed. she had right hemianopsia on initial exam and was also confused but followed simple commands. head ct day after admission showed a roughly 20cc bleed in the left occipital lobe, cortical, round appearing, with some interventricular extension, no hydrocephalus. the patient was loaded with dilantin in the ed. she was initially admitted to the intensive care unit. the patient was very hypertensive on admission. her bp was initially controlled in the icu with nipride, then switched to nicardipine. she was in the icu for several days as her blood pressure was difficult to control. eventually she was transitioned to po hctz, [**last name (un) **], labetalol and hydralazine. hctz was later stopped because of hyponatremia. glycemic control was maintained with riss. she was transferred out of the icu to neurology service on [**2171-12-27**]. the patient had been intermittently very agitated and aggressive which delayed mri/mra planned for work up of her occipital bleed. on [**2171-12-29**] she developed mental status changes, became more somnolent, lethargic. non-contrast head ct was obtained which now showed new infarction in the right occipital lobe. mri/mra were done and were unrevealing for potential cause of the patient's bilateral occipital events. the etiology of her bleed felt most likely to be a hemorrhagic transformation of an occipital infarct, although extension of hemorrhage into the ventricle is difficult to explain in this setting. other possibilities for occipital hemorrhage in this patient are amyloid angiopathy and less likely htn. mri/mra were negative for mass or aneurysm. the patient has atrial fibrillation (was not on anticoagulation) which is a potential source of thromboembolism to the brain. transthoracic echo was also checked and did not show thrombi or vegetations. at the time of discharge the patient could see some movements and larger objects. she was oriented to self and place. she followed simple commands but her mental status was not improved enough for safe self feeding. she had g-j tube placed on [**2172-1-3**] by interventional radiology. prior to discharge, she was tolerating tube feeds without difficulty. she will need to have her gastric tube changed in 3 months. 2. confusion, likely secondary to the occipital lobe bleed vs. uti. the patient was given a banana bag on admission. tsh was checked and was normal. rpr was non-reactive. folate >20. b12 was borderline low, and the patient was started on supplements. lfts were normal. 3. seizure-like activity. on evening of admission ([**12-24**]), the patient had seizure like activity with tonic arm posturing and eye gaze. dilantin level was checked and was therapeutic. seizure activity may have been due to the cortical bleed, or may have been secondary to hypokalemia (k 2.9). dilantin was continued and ms. [**known lastname 58814**] required reloading to keep dilantin level closer to therapeutic range. she was continued on dilantin until peg tube placement. dilantin was stopped prior to discharge. 4. leukocytosis. the patient's wbc peaked at 20k on [**2172-10-28**]. she remained afebrile throughout her hospitalization. she was started on levaquin on [**12-24**] for uti diagnosed at the outside hospital. chest x-ray on [**2171-12-29**] showed new retrocardiac opacity suggestive of atelectasis or new infiltrate or effusion. flagyl was added on [**2171-12-29**] given rising wbc to cover for possible aspiration pneumonia. the patient was maintained on aspiration precautions. the patient did not have sputum to send for culture. bilateral effusions were noted on cxr and chest ct. the patient had no diarrhea and her abdominal exam was benign. c. diff toxin was negative. the patient's wbc started to trend down on [**2172-10-29**]. the patient completed a course of levaquin and flagyl. crp and esr were checked because of concern for persistent leukocytosis and came back at 110 and 18.7, respectively. however, given recent cerebral infarct, hemorrhage, g/j tube placement and recent infection. breast exam was done and was negative. she had no lad. leukocytosis was attributed to recent infection. the patient will need outpatient follow up to ensure that she is up to date on all age appropriate cancer screening. the patient or family did not know the contact information or spelling of the pcp's last name ? dr. [**last name (stitle) 58815**]. 5. anemia, normocytic. hct dropped from 35 to 29, but remained stable at around 30. then it dropped again from 29 to 25 and the patient was transfused one unit of prbcs. there was no localizing source of bleeding and decrease in hct was attributed to dilutional effect. hemolysis labs were negative. reticulocyte count 2.4%. iron studies (pre-transfusion) were checked and reveled low normal serum iron, elevated ferritin and slightly low tibc. the above picture is most c/w anemia of chronic disease but would recommend rechecking when the patient is over acute illness. the patient needs to have complete work up for amenia as an outpatient. serum and urine protein electrophoresis was sent and the results were still pending at the time of discharge. b12 level was borderline low thus the patient was given b12 in the hospital. 6. hypertension. patient's blood pressure was difficult to control. her medications were adjusted. on [**1-2**] the patient had a hypertensive episode with sbp in 250's while she was in interventional radiology for peg tube placement due to missed doses of po meds. her mental exam after this episode was unchanged. stat head ct was obtained and showed on changes. ekg was also unchanged. her systolic blood pressures have been in 130's on the day of discharge on irbesartan, labetalol, and hydralazine. 7. renal insufficiency. baseline cr is unknown. fe na calculated to be 0.1% which is consistent with prerenal failure. she was rehydrated gently with ns at 80cc/hr. her cr stayed between 0.9 and 1.5. 8. atrial fibrillation. original ekg showed afib. the patient was monitored on telemetry and would go in/out of afib. she was not anticoagulated initially given acute intracranial hemorrhage. she was rate controlled on labetalol with hr in 60's. head ct on [**2172-1-2**] showed no new hemorrhage or progression of existing hemorrhage. the patient was started on coumadin on [**2172-1-6**]. goal inr [**12-19**]. her coumadin level needs to be monitored and coumadin dose adjusted. 9. hyponatremia. the patient's na went down to 128. this felt to be likely secondary to hctz as work up was c/w renal wasting. hctz was stopped. serum osm 285. urine osm 485. urine na (on hctz) was 47. fena 1%. the patient was started on standing lasix prior to discharge and her electrolytes need to be carefully monitored. 10. urethral nodule. this was noted by nursing staff during foley catheter change. the 1 cm smooth pink/purple pedunculated nodule inside urethra did not appear infected but was tender. urology were consulted for management recommendations. they did not feel that immediate intervention was necessary and recommended outpatient follow up which was arranged. 11. pulmonary nodules. chest ct was done for evaluation of the nodule that was seen on chest x-ray. this was not confirmed on chest ct and felt to be an artery or artifact. final chest ct results showed two 3 mm rul nodules, paraesophageal lymph node, pulmonary effusions, and vertebral compression fracture. pulmonary nodules seen on chest ct will need to be followed up with repeat chest ct to evaluate for interval changes. 12. volume overload. the patient developed anasarca and total body volume overload likely secondary to retention due to poor nutritional status, diastolic dysfunction, and possible as an adverse reaction to medications causing water retention. she was started on lasix prior to discharge with the goal of negative 1 liter volume balance a day. she will need daily weights and frequent reassessment of her volume status. 13. fen: the swallowing evaluation was attempted, however, the patient was confused and not cooperative. ngt was placed and tf started. peg tube was placed on [**1-3**] for nutrition because the patient's mental status and cooperation remained poor to allow for independent feeding. she was tolerating tube feedings well. 14. prophylaxis: ppi, pneumoboots, sc heparin, bowel regimen. 15. full code medications on admission: 1. hctz/lisinopril 20/25 2. hctz/irbesartan 12.5/300 3. doxepin 50mg daily 4. paxil 20 mg daily discharge disposition: extended care facility: [**hospital 58816**] rehab discharge diagnosis: 1. left occipital hemorrhage 2. right occipital infarction 3. cortical blindness 4. anemia 5. atrial fibrillation 6. renal insufficiency 7. hypertension 8. urinary tract infection 9. bilateral pleural effusions 10.urethral nodule discharge condition: patient is cortically blind. she is able to see movements and some larger objects. she follows simple commands, oriented to self and place. she did not pass swallowing evaluation dut to poor cooperation/mental status. discharge instructions: take all medicines as prescribed. keep all follow-up appointments. call your doctor or return to the ed if you develop sudden weakness of an arm or leg, difficulty speaking or understanding, slurring of your speech or difficulty swallowing. followup instructions: please call to schedule a follow up appointment with the primary care physician, [**last name (namepattern4) **]. [**last name (stitle) 58815**] (?spelling, unable to obtain contact information for the primary care provider from the patient or family). the patient will need a follow up appointment in [**11-17**] weeks after discharge from a nursing facility. the patient will need to follow up regarding lab results that were still pending at the time of discharge. please follow up with [**name6 (md) 4267**] [**last name (namepattern4) 4268**], md, phd. where: [**hospital 273**] neurology phone:[**telephone/fax (1) 657**] date/time:[**2172-3-4**] 1:30 please follow up with dr. [**last name (stitle) 770**] in urology for urethral nodule. appointment schedules for [**2172-1-29**] at 2 pm. office located at [**hospital1 9384**] on the 6 th floor. phone ([**telephone/fax (1) 58145**]. please call [**telephone/fax (1) 58817**] to schedule a g/j tube change in 3 months (due [**2172-4-1**]). [**name6 (md) **] [**name8 (md) **] md, [**md number(3) 632**]",1
55,"admission date: [**2143-3-28**] discharge date: [**2143-4-2**] date of birth: [**2114-5-11**] sex: f service: medicine allergies: aspirin / iodine / nsaids / opioid analgesics attending:[**first name3 (lf) 5806**] chief complaint: flushing and tachycardia major surgical or invasive procedure: none history of present illness: ms [**known lastname 2696**] is a 28 year old woman with a 9 yr history of systemic mastocytosis, with 2 recent admissions for flares, presenting with an acute flare which began last night. . she woke from sleep with symptoms of skin flushing and palpitations and wanted to seek medical care before things got worse. she denies n/v, abdominal pain and diarrhea which normall accompany her flares. she cannot identify a particular trigger. since her last admission 2 weeks ago, she has been having some flushing nightly, and several episodes of ""[**known lastname 500**] pain"" in her wrists, elbows, shoulders and back which is new for her. she is still on a prednisone taper from her last flare earlier this month at which time she was admitted from [**date range (1) 59412**]. that flare occured while still on a prednisone taper from a flare in late [**month (only) 404**] attibuted to a viral illness. the patient is used to having flares only 2-3 times per year, and never while still on a prednisone dose. . her first episode began at age 19 with flushing associated with hypotension and heart racing. she was diagnosed 3yrs later in [**2136**] when tryptase levels were noted to be elevated. she has not had a successful [**year (4 digits) 500**] marrow biopsy in the past despite 2 attempts at ucsf. triggers include stress, nsaids, asa, opiates, and iodine including contrast dyes. . in the ed vitals: t 97.6 hr 97 150/87 rr 20 o2 sat 100% ra. patient given 125mg solumedrol, 50mg iv benadryl x 2, famotidine and tylenol 650 mg po x1 and ns iv fluids. the patient's symptoms improved and she was admitted to the floor. . this morning, the patient feels well and symptoms are mostly resolved. she remains very anxious about her conditions and making sure the flare does not return, and is concerned with the apparent recent progression of her illness. she also admits to increase stress secondary to her condition, and is becoming more convinced that some therapy may be useful to her. she was recently started on as standing lorazepam dose of 0.5mg [**hospital1 **] by her allergist to help her stay more calm. past medical history: -systemic mastocytosis, followed by dr.[**last name (stitle) 2603**], allergy specialist and dr. [**last name (stitle) **] of [**hospital1 112**] -history of coffee ground emesis in the setting of mastocytosis flare and nausea/vomitting in [**7-/2142**] -anemia, low normal mcv, iron panel in [**3-/2141**] iron 79, tibc 364, ferritin 55, transferin 280, in [**10/2142**] normal b12 and folate -thumb surgery -tonsillectomy -hemorrhoids social history: patient employed as a librarian. honorably discharged from air force in [**2139**] due to her recurrent mastocytosis flares and hospitalizations. married, no children. does not smoke or use drugs, social drinker. family history: father alive and in good health, mother has ms. [**name13 (stitle) **] family h/o allergic, rheumatologic, or autoimmune diseases. grandfather with cad, colon ca and grandmother with skin ca. physical exam: physical examination: vs: 98.3 129/91 108 18 100% ra gen: nad, awake, alert heent: eomi, perrl 9->5, sclera anicteric, conjunctivae clear, pale, op moist and without lesion neck: supple, no jvd, no lad cv: slightly tachycardic, normal s1, s2. no m/r/g. chest: resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abd: protuberent, soft, nt, nd, no hsm ext: no c/c/e, 2+ radian and pt pulses skin: erythematous macular region on left face. no decoloration on legs or arms. neuro: no focal findings, a ox3 psych: appears somewhat anxious, near tearful when discussing her disease. overall appropriate. pertinent results: chest (pa & lat) [**2143-3-28**]: impression: no acute cardiopulmonary process. hematology: [**2143-3-27**] 11:55pm blood wbc-12.6* rbc-3.84* hgb-11.4* hct-32.2* mcv-84 mch-29.6 mchc-35.3* rdw-15.0 plt ct-292 [**2143-3-30**] 09:00am blood wbc-14.7* rbc-3.31* hgb-9.9* hct-29.7* mcv-90 mch-30.0 mchc-33.5 rdw-15.0 plt ct-207 [**2143-4-2**] 06:00am blood wbc-17.9* rbc-4.54 hgb-13.3 hct-38.4 mcv-85 mch-29.2 mchc-34.6 rdw-14.9 plt ct-335 coags: [**2143-3-28**] 06:00am blood pt-13.0 ptt-26.0 inr(pt)-1.1 [**2143-3-31**] 08:45am blood pt-16.1* ptt-24.3 inr(pt)-1.4* [**2143-4-1**] 06:15am blood pt-14.8* ptt-25.2 inr(pt)-1.3* chemistry: [**2143-3-28**] 06:00am blood glucose-126* urean-8 creat-0.9 na-141 k-4.1 cl-106 hco3-23 angap-16 [**2143-3-28**] 06:00am blood calcium-9.4 phos-3.2 mg-2.2 [**2143-3-28**] 06:00am blood ld(ldh)-235 alkphos-54 [**2143-3-31**] 08:45am blood glucose-125* urean-16 creat-0.7 na-141 k-4.1 cl-109* hco3-21* angap-15 [**2143-3-31**] 08:45am blood calcium-9.0 phos-3.1 mg-2.2 [**2143-4-1**] 06:15am blood glucose-114* urean-17 creat-0.8 na-143 k-4.0 cl-106 hco3-26 angap-15 [**2143-4-1**] 06:15am blood calcium-9.1 phos-4.1 mg-2.4 urine: [**2143-3-28**] 12:00am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-tr bilirub-neg urobiln-neg ph-5.0 leuks-neg miscellaneous: test result reference range/units tryptase 98 h [**3-12**] ng/ml brief hospital course: ## mastocytosis: pt has a 9 yr history of the systemic mastocytosis, with flares normally 3/year. this is patient's 3rd flare in 2 months, while still on steroid taper and [**month/year (2) 500**] pain which is new for her. she responded well to 125 mg iv steroids q 8 hrs and iv diphenydramine in addition to her continuing home regimen. cbc was at her baseline, w/normal differential. [**month/year (2) **] pain was investigated with ldh and alkphos which were both wnl. her new [**hospital1 112**] allergist, dr. [**last name (stitle) **] was contact[**name (ni) **]. she recommended repeating her serum tryptase, ordering a 24 hr urine histamine, and if possible performing an aspirin challenge in house. serum tryptase revealed a high value at 84. the patient has a particularly high level of urine prostaglandins, making aspirin therapy an ideal treatment. unfortunately, she had a possible flare [**3-4**] aspirin in [**2136**]. the challenge was performed the day of admission and an adverse reaction at the maximum aspirin dose resulted in an icu course. she was stabilized on iv steroids and iv benadryl and transferred back to the medical floor. she continued on her home histamine receptor blockers and was transitioned from iv to po steroids and benadryl and observed overnight prior to discharge on a steroid taper as recommended by dr. [**last name (stitle) 2603**], [**hospital1 18**] allergist. she had no further symptoms of flushing or tachycardia following transfer from the icu to the medical floor and was discharged on her home meds, prednisone taper, gi prophylaxis with ppi, calcium and vitamin d, and ss bactrim for pcp [**name initial (pre) 1102**]. ## anxiety/depression: pt admitted to a problem with worsening anxiety, and that she appreciates the sedative affect of her iv diphenhydramine. she had been feeling down since her severe flare in [**2142-10-1**], and that she does not go out with her husband because she fears a flare. she denied hopelessness or intent to harm self or others. she has agreed to outpatient therapy and has been referred. per pcp [**name initial (pre) **]'s she is discharged on 0.5 ativan tid prn up from [**hospital1 **]. medications on admission: 1. cetirizine 10 mg tablet sig: one (1) tablet po twice a day. 2. cromolyn 100 mg/5 ml solution sig: two hundred (200) mg po four times a day. 3. doxepin 50 mg capsule sig: one (1) capsule po twice a day. 4. epipen 0.3 mg/0.3 ml pen injector sig: one (1) injection intramuscular once as needed for as directed.- confirmed not expired 5. hydroxyzine hcl 50 mg tablet sig: one (1) tablet po twice a day. 6. ativan 0.5 mg tablet sig: one (1) tablet po twice a day as needed for anxiety. 7. montelukast 10 mg tablet sig: one (1) tablet po daily 8. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid 9. prednisone taper (currently on 30 mg daily but took a total of 60 mg today at home due to flare) 10. nuvaring 11. cromolyn cream (not currently using) 12. ketotifen 2mg [**hospital1 **] (canadian medication) discharge medications: 1. cetirizine 10 mg tablet sig: one (1) tablet po bid (2 times a day). 2. montelukast 10 mg tablet sig: one (1) tablet po daily (daily). 3. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 4. ketotifen sig: two (2) mg po twice a day. 5. nuvaring 0.12-0.015 mg/24 hr ring sig: one (1) vaginal once a month. 6. bactrim 80-400 mg tablet sig: one (1) tablet po once a day: please take once daily as long as you are taking prednisone. disp:*30 tablet(s)* refills:*2* 7. caltrate-600 plus vitamin d3 600-400 mg-unit tablet sig: one (1) tablet po twice a day: please take once daily as long as you are taking prednisone. disp:*60 tablet(s)* refills:*2* 8. cromolyn 100 mg/5 ml solution sig: ten (10) ml po qid (4 times a day) as needed for mastocytosis. 9. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day): please take twice daily as long as you are taking prednisone. disp:*60 capsule, delayed release(e.c.)(s)* refills:*2* 10. hydroxyzine hcl 25 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 11. lorazepam 0.5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for anxiety. disp:*30 tablet(s)* refills:*0* 12. doxepin 25 mg capsule sig: two (2) capsule po bid (2 times a day). 13. prednisone 10 mg tablet sig: five (5) tablet po twice a day for 5 days: at end of 5 days, on [**2143-4-7**], start once daily prednisone taper as instructed. 14. prednisone 10 mg tablet sig: as per taper. tablet po once a day for 9 weeks: after 5 days of 50 mg twice daily, starting on [**2143-4-7**] take 6 pills for 5 days, 5 pills for 7 days, 4 pills for 7 days, 3 pills for 7 days, 2 pills for 7 days, 1.5 pills for 7 days, 1 pill for 7 days, 0.5 pill for 7 days. disp:*210 tablet(s)* refills:*0* 15. diphenhydramine hcl 25 mg capsule sig: [**2-1**] capsules po q6h (every 6 hours) as needed. discharge disposition: home discharge diagnosis: primary diagnosis: mastocytosis secondary diagnosis: anxiety discharge condition: hemodynamically stable discharge instructions: you were admitted to the hospital with flushing and a fast heart rate, consistent with a flare of your mastocystosis. you were treated with iv steroids, iv benadryl, and your home medications. you have been discharged on a gradual steroid taper, since you have been on steroids for over 6 weeks now. please continue to take you medicines as directed, the changes you should make are as follows: prednisone taper: 50 mg twice daily for 5 days, 60 mg once daily for 5 days, 50 mg once daily for 7 days, 40 mg once daily for 7 days, 30 mg once daily for 7 days, 20 mg once daily for 7 days, 15 mg once daily for 7 days, 10 mg once daily for 7 days, 5 mg once daily for 7 days. caltrate 600 + d: one tablet twice daily while on prednisone to prevent [**month/day (2) 500**] loss. omeprazole: one tablet twice daily while on prednisone to prevent ulcer. bactrim: one tablet every day while on prednisone to prevent infections. please attend the follow up appointments listed below. please seek medical help if you experience more signs of a worsening flare, chest pain or pressure, severe fever, or any other concerning symptoms. followup instructions: provider: [**name10 (nameis) **] [**apartment address(1) **] (st-3) gi rooms date/time:[**2143-4-9**] 8:30 provider: [**first name8 (namepattern2) **] [**name11 (nameis) **], md phone:[**telephone/fax (1) 463**] date/time:[**2143-4-9**] 8:30 provider: [**first name4 (namepattern1) **] [**last name (namepattern1) **], md phone:[**telephone/fax (1) 5808**] date/time:[**2143-4-11**] 4:00 completed by:[**2143-4-7**]",1
56,"admission date: [**2176-12-13**] discharge date: [**2176-12-19**] service: neurology allergies: sulfa (sulfonamide antibiotics) / ativan attending:[**first name3 (lf) 2569**] chief complaint: right visual field cut and confusion. major surgical or invasive procedure: none. history of present illness: 88 year old woman with history of htn initially presenting this morning with an occipital stroke. per report she was an active healthy woman who painted a fence last week. she was brought in to the hospital this morning after a syncopal episode and acute onset of neurological deficits and was diagnosed with a large left pca territory stroke. she was transferred to [**hospital1 18**] for further workup and treatment. yesterday morning the patient had 1 episode of desaturations to 80% but had just gotten 1 dose of ativan. they gave her 3l nc and she bounced back to 90s. at 2am this morning (1 hour ago) she triggered on the floor for desaturations briefly down to 80%. she was placed on 4l nc then 5l nc and then on a non-rebreather on which she was sating ~88% and then increased to 97% when the head of the bed was raised. an abg and cxr were normal. lungs were clear on exam. she was noted to be tachypneic and hypertensive and in a sinus tach at 95. bps ranging 175/120, ekg showed no evidence of right heart strain. no fever or chills. denies any current shortness of breath or cough although cough noted by neurology team this evening. no witnessed aspiration event. review of systems: (+) per hpi (-) denies fever, chills, 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: hypertension h/o shingles in [**2176-10-9**] left macular degeneration hearing loss with hearing aids mild cognitive loss s/p lle phlebitis in [**2167**] varicose veins osteoarthritis s/p foot surgery in [**2165**] social history: no smoking, etoh, illicits. son and daughter at bedside. son is hcp ([**telephone/fax (1) 51694**]) patient lives with her daughter, who previously worked as a nurse. complicated social family history. family history: mom died of colon cancer. dad died of mi. no h/o strokes. physical exam: summary of neurologic exam findings: mrs.[**known lastname 51695**] key exam findings are: right homonymous hemianopia, anomia, anterograde amnesia. please see brief hospital course for anatomical correlation of these findings and realtionship to her stroke. admission examination: 96.8 73 150/104 18 96% 2l gen: lying in bed, nad heent: normocephalic, atraumatic. mucous membranes moist. neck: supple back: no point tenderness or erythema cv: rrr, nl s1 and s2, no murmurs/gallops/rubs lung: clear to auscultation bilaterally abd: +bs soft, nontender skin: no rash ext: no edema neurologic examination: mental status: general: alert, awake, agitated. orientation: oriented to person, ""hospital"" (doesn't know which one). cannot name month of year. attention: says days of the week forwards but stops after 5 days; unable to to say days of the week backwards executive function: follows simple axial and appendicular commands. requires step-by-step prompts for complex commands. memory: registration [**4-10**]. recall 0/3 at 5 minutes. speech/language: when lying down, speech is fluent w/o paraphasic (phonemic or semantic) error. when sitting up, however, patient has significant word substitution and invents words. when asked to name objects on the stroke card, she makes up words. then she says, ""i can't see anything without my roof."" appears frustrated by inability to come up with the correct word. comprehension seems intact. unable to read. praxis: able to demonstrate how to brush teeth. calculations: unable to calculate 9 quarters. cranial nerves: ii: pupils equally round and reactive to light, 2 to 1.5 mm bilaterally. dense right visual field cut. looks at $20 [**doctor first name **] in left visual field and follows it. she also is able to copy the examiner when shown how to do various parts of the exam (this was often done due to difficulty hearing). however, later in the exam when testing finger-nose-finger in the sitting position, the patient was unable to find the examiner's finger regardless of visual field. iii, iv, vi: extraocular movements intact without nystagmus. v1-3: sensation intact v1-v3. vii: facial movement symmetric. viii: significant hearing difficulty throughout exam; examiner needs to yell for patient to understand. ix & x: palate elevation symmetric. uvula is midline. [**doctor first name 81**]: sternocleidomastoid and trapezius full strength bilaterally. xii: good bulk. no fasciculations. tongue midline, movements intact. motor: normal bulk bilaterally. tone normal. no observed myoclonus or tremor. no pronator drift delt; c5 bic:c6 tri:c7 wr ext:c6 fing ext:c7 left 5 5 5 5 5 right 5 5 5 5 5 ip: quad: hamst: dorsiflex: [**last name (un) 938**]:pl.flex left 5 5 5 5 5 5 right 5 5 5 5 5 5 deep tendon reflexes: biceps: tric: brachial: patellar: achilles toes: right 1 1 1 1 1 withdraw left 1 1 1 1 1 withdraw sensation: intact to light touch throughout. no extinction to double simultaneous stimulation. coordination: finger-nose-finger limited as patient appears unable to see the examiner's finger; she is able to touch her nose with very mild right-sided dysmetria. heel to shin normal, rams normal. gait: not tested due to pressure-dependent exam. pertinent results: on admission: [**2176-12-12**] 09:45pm blood wbc-6.0 rbc-4.44 hgb-14.0 hct-40.3 mcv-91 mch-31.4 mchc-34.7 rdw-15.7* plt ct-148* [**2176-12-12**] 09:45pm blood neuts-86.3* lymphs-9.7* monos-3.3 eos-0.4 baso-0.4 [**2176-12-12**] 09:45pm blood pt-12.4 ptt-28.0 inr(pt)-1.0 [**2176-12-12**] 09:45pm blood glucose-110* urean-10 creat-0.7 na-136 k-3.7 cl-101 hco3-25 angap-14 [**2176-12-13**] 07:40am blood alt-18 ast-24 ck(cpk)-106 alkphos-73 totbili-0.4 [**2176-12-12**] 09:45pm blood ctropnt-<0.01 [**2176-12-12**] 09:45pm blood cholest-223* [**2176-12-13**] 07:40am blood calcium-9.1 phos-2.3* mg-1.9 cholest-241* [**2176-12-13**] 07:40am blood %hba1c-5.7 eag-117 [**2176-12-12**] 09:45pm blood triglyc-54 hdl-82 chol/hd-2.7 ldlcalc-130* [**2176-12-13**] 07:40am blood tsh-3.4 [**2176-12-12**] 09:45pm blood asa-6.9 ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg [**2176-12-14**] 01:37am blood type-art fio2-95 po2-81* pco2-38 ph-7.46* caltco2-28 base xs-2 aado2-562 req o2-92 intubat-not intuba [**2176-12-14**] 01:34pm blood lactate-1.3 [**2176-12-14**] 01:34pm blood o2 sat-92 [**2176-12-12**] 10:30pm urine color-yellow appear-clear sp [**last name (un) **]-1.008 [**2176-12-12**] 10:30pm urine blood-sm nitrite-neg protein-tr glucose-neg ketone-50 bilirub-neg urobiln-neg ph-7.0 leuks-tr [**2176-12-12**] 10:30pm urine rbc-0-2 wbc-0-2 bacteri-none yeast-none epi-0-2 [**2176-12-12**] 10:30pm urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg mrsa screen (final [**2176-12-17**]): no mrsa isolated. ct head (osh) hypodensity in pca distribution, not involving brainstem, but whole of left occipital pole, through inferior temporal lobe and left hippocampus to temporal pole. ecg [**2176-12-12**]: sinus rhythm. left axis deviation consistent with left anterior fascicular block. qrs axis minus 45 degrees. first degree a-v delay. delayed r wave transition in the anterior precordial leads, may be due to left anterior fascicular block but cannot exclude anteroseptal wall myocardial infarction, age indeterminate. clinical correlation is suggested. possible left ventricular hypertrophy. non-specific inferior and lateral st-t wave changes. no previous tracing available for comparison. cta neck [**2176-12-13**]: impression: 1. left occipital infarct. 2. narrowing of the left pca p2 bifurcation segment. atheromatous disease involving the left proximal vertebral artery. 3. small low density right thyroid nodule measuring about 8mm. clinical and tft evaluation advised prior to us. tte [**2176-12-14**]: the left atrium is normal in size. there is moderate symmetric left ventricular hypertrophy. the left ventricular cavity is unusually small. regional left ventricular wall motion is normal. left ventricular systolic function is hyperdynamic (ef>75%). there is an abnormal systolic flow contour at rest, but no left ventricular outflow obstruction. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the right ventricular free wall is hypertrophied. the ascending aorta is mildly dilated. the number of aortic valve leaflets cannot be determined. the aortic valve leaflets are moderately thickened. no masses or vegetations are seen on the aortic valve. significant aortic stenosis is present (not quantified). moderate (2+) aortic regurgitation is seen. the aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is a very small pericardial effusion. impression: small lv cavity size with moderate symmetric lvh and hyperdynamic lv systolic function. abnormal lvot systolic flow contour without frank obstruction. probable diastolic dysfunction. calcified mitral and aortic valve with at least mild aortic stenosis, moderate aortic regurgitation and mild mitral regurgitation. no cardiac source of embolism seen. cta chest [**2176-12-14**]: impression: 1. no pulmonary embolism. 2. enlarged thoracic aorta as described. no aortic dissection. 3. liver hypodensities, too small to characterize. 4. bibasilar atelectasis with trace left effusion. abdominal x-ray [**2176-12-15**]: there is no evidence of obstruction or ileus. there is increased fecal material throughout the colon. there are degenerative changes in the thoracic and lumbar spine. tte [**2176-12-16**]: after intravenous injection of agitated saline, there is prompt (within one beat) and prominent appearance of saline contrast in the left heart c/w a right-to-left shunt across the interatrial septum. the ascending aorta is mildly dilated. the aortic valve leaflets are moderately thickened. significant aortic regurgitation is present, but cannot be quantified. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of [**2176-12-14**], a right-to-left shunt, likely at the atrial level is now identified. video swallow [**2176-12-16**]: impression: no aspiration. moderate amount of gastroesophageal reflux. barium swallow [**2176-12-16**]: impression: ineffective primary peristalsis. minimal reflux seen. possible small hiatal hernia. no evidence of stricture. duplex ultrasound of lower extremities: impression: no evidence of deep vein thrombosis in either leg. brief hospital course: active problems during admission were neurologic (secondary to left posterior cerebral artery infarction), paroxysmal hypoxic respiratory failure, hypertension, along with other issues listed below. stroke mrs. [**known lastname 23081**] presented initially with lightheadedness, confusion and headache followed by dragging of right foot and insensible speech. ct head at osh showed left occipital hypodensity extending into left temporal region. she was seen by neurology service who recommended cta head and neck which showed narrowing of the left pca p2 bifurcation segment and atheromatous disease involving the left proximal vertebral artery. she was kept on aspirin and statin. bp was allowed to autoregulate with goal sbp 140-180. mi was ruled out with cardiac enzymes. she also had tte with bubble study that showed a right to left shunt. ultrasound of both lower extremities did not reveal thrombus. in view of the alternative explanation for this presentation offered by vertebral disease and the high prevalence of septal defects in the general population, without evidence of a source and only in the presence of no other explanation would this be invoked as causal. aspirin was changed to aggrenox prior to discharge given dyspepsia and superiority in secondary prevention. hypoxic respiratory failure on the day following admission, desaturation to the 80s was noted and mrs. [**known lastname 23081**] was transferred to the icu for close monitoring (being transferred back to the floor subsequently) most likely positional as patient's o2 saturations apparently rose quickly after sitting up. cta was negative for pe. she had no evidence of chf on cxr or exam. tte showed probable diastolic dysfunction but preserved ef. on [**2176-12-15**], she desaturated to 80%'s and had to be put on a non-rebreather briefly. oxygen saturations remained in high 90%'s on room air for remainder of hospital stay. a bubble study was performed. atrial septal defect bubble study was consistent with atrial septal defect but it was felt that her stroke was more likely attributable to vertebral disease than paradoxical emboli. cardiology thought that this was a possible underlying cause of desaturation, but felt that this was unlikely given the paroxysmal nature of her desaturations that were more frequent during sleep. this will need to be followed in rehabilitation, but as an inpatient, such events did not occur later in the admission. dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **], who saw her during this admission, will see her as an outpatient for further evaluation. again, we do not attribute her stroke to this defect. thyroid nodule of note, cta also revealed a small low density right thyroid nodule measuring about 8 mm. she should get tft's prior to ultrasound and this should be followed as an outpatient. hypertension pt remained hypertensive, reaching systolic 200's. per neuro, bp was allowed to autoregulate with goal bp 140-180 systolic. she was controlled with hydralazine for sbp above 180's. lisinopril was restarted at 5 mg, resulting in improved control. blood pressure is best lowered gradually in this context, with uptitration of acei most desirable. chest pain in the icu, she had episodes of chest pain often precipitated by food intake. ekg remained unchanged from prior. cardiac enzymes were negative. she was put on a nitro gtt at one point as she was hypertensive to systolic 190's. she was kept on full dose aspirin. given negative cardiac work-up and relation to food intake intake, gi was consulted. dyspepsia kub was unremarkable. gi recommended barium esophagram which showed no strictures but did show ineffective primary peristalsis, minimal reflux, and possible small hiatal hernia. gi recommended that pt have outpatient gi appointment if symptoms continue. if symptoms continue by the time of this appointment, gi will consider egd to rule out esophagitis. bradycardia pt had a few episodes of bradycardia precipitated by po intake which were attributed to increased vagal tone in the context of dyspepsia. ativan adverse reaction we noted that even taking her home dose of ativan resulted in marked sedation. we would suggest avoiding benzodiazepines. leg cramps not an active problem during admission. medications on admission: lisinopril one tab (dose unknown) po daily lorazepam 0.5-1mg po daily prn insomnia, anxiety quinine prn leg cramps discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. senna 8.6 mg tablet sig: one (1) tablet po hs (at bedtime). 3. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day): can stop when ambulating frequently. 4. alum-mag hydroxide-simeth 200-200-20 mg/5 ml suspension sig: 15-30 mls po qid (4 times a day) as needed for indigestion. 5. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 6. hydrocortisone 0.5 % cream sig: one (1) appl topical tid (3 times a day) as needed for rash . 7. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours) as needed for gerd. 9. dipyridamole-aspirin 200-25 mg cap, multiphasic release 12 hr sig: one (1) cap po daily (daily) for 4 days: after four days, increase to [**hospital1 **]. 10. dipyridamole-aspirin 200-25 mg cap, multiphasic release 12 hr sig: one (1) cap po bid (2 times a day): do not start until four days of once daily dosing is completed. 11. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). discharge disposition: extended care facility: [**hospital3 1107**] [**hospital **] [**hospital 1108**] rehab unit at [**hospital6 1109**] - [**location (un) 1110**] discharge diagnosis: primary stroke - ischemic, left posterior cerebral artery atrial septal defect vertebral stenosis secondary hypertension discharge condition: mental status: confused - always. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). at baseline she has been more independent, but this is our present recommendation. she has complete right visual field loss and memory impairment. she cannot typically encode new memories at present, particularly when these are episodic or linguistic. discharge instructions: you came to the hospital after having a stroke. this was of the back part of your brain and involves brain areas important for your right visual field (left occipital lobe), along with a brain region important for memory formation (left hippocampus). this has occurred in the context of narrowing of a blood vessel that supplies these regions (vertebral artery). we adjusted your medications to include an antiplatelet [**doctor last name 360**], aggrenox. now that you are medically [**last name (un) 2677**], we feel that you will now benefit from rehabilitation, where you will adapt to the changes that have occurred as a result of this stroke. please attend follow-up listed below. please continue to take your medications as directed. followup instructions: please follow-up in stroke clinic. provider: [**first name8 (namepattern2) **] [**name11 (nameis) 162**], md phone:[**telephone/fax (1) 2574**] date/time:[**2177-1-17**] 10:30 please follow-up with cardiology: dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] [**2177-1-9**] at 13:00. [**hospital ward name 23**] [**location (un) **], [**hospital1 18**] [**hospital ward name 5074**]. please follow-up with gastroenterology if your dyspepsia continues: [**last name (lf) 2643**], [**first name3 (lf) **] b office phone: ([**telephone/fax (1) 2306**] office location: lmob 8e department: gi, medicine organization: [**hospital1 18**] please see your primary care doctor (we have not made an appointment, because you will be at rehabilitation) as soon as you are discharged from rehabilitation. [**last name (lf) **],[**first name3 (lf) **] l. [**telephone/fax (1) 5294**]. if your primary care doctor would like you to see a cardiologist again, you could make an appointment to see dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] at [**hospital1 69**]. [**first name8 (namepattern2) **] [**name8 (md) 162**] md [**md number(2) 2575**]",1
57,"admission date: [**2107-11-21**] discharge date: [**2107-12-9**] date of birth: [**2087-9-18**] sex: f service: medicine allergies: amoxicillin / penicillins / neurontin / erythromycin / iv dye, iodine containing / optiray 350 / compazine attending:[**first name3 (lf) 783**] chief complaint: anaphylactoid reaction to iv contrast major surgical or invasive procedure: none history of present illness: ms [**known lastname 22473**] is a 20 year-old female with history of relapsing/remitting multiple sclerosis who presented to [**hospital1 1535**] emergency department on [**2107-11-20**] with left flank pain. she describes her pain as ""achy"" discomfort which began approximately 10 days prior to admission, wrapping around to her lower back, worse with movement, slightly better with ibuprofen. she also notes that the discomfort is worse with urination, mainly a ""pressure"" on the left side. she denies associated hematuria/dysuria. she denies n/v/diarrhea/abdominal pain/blood in stool/tarry colored stool. she also reports left hip pain which developed over the same time period for which she was seen by her pcp earlier this past week and was diagnosed with probable bursitis. she reports that the flank pain has progressively worsened over the past 10 days so that her mother who works in the sicu at [**hospital1 18**] referred her to the ed for further evaluation. . in the ed, initial vitals were t 98.5 p 85 bp 102/66 rr 16 o2sat 100% ra. cbc, chemistries, and lfts were normal and ua was negative. she received 1mg iv morphine x2. plan was made for ct abdomen/pelvis to assess for possible kidney stone; if stone was not present, then plan was to proceed with administration of iv contrast to further assess for other etiologies of her left flank pain. after initial scan failed to demonstrate kidney stone, iv contrast was administered. within approximately one minute of receiving iv contrast she reports feeling chest heaviness and difficulty breathing. she also reports that her face became swollen, she itched all over and that her throat was itchy. she shouted ""i can't breathe"" while in the ct scanner and was immediately removed from the scanner. she was treated emergently for presumed life-threatening anaphylactoid reaction to iv contrast; in this setting, she received 1 ml of 1:1000 epinephrine (1 mg) intravenously. she was then transferred back to the emergency department and treated with solumedrol, famotidine, benadryl, and bronchodilator nebulizers. she was tachycardic to the 120s and hypotensive to systolic pressure in the 70's, and received intravenous fluid resuscitation with 4 liters of normal saline. she then developed hypoxia and cough with frothy pink sputum, requiring supplemental oxygen by non-rebreather mask. ekg was notable for ischemic st depressions in the inferolateral leads. her cardiac enzymes (normal on presentation) were elevated (troponin of 0.43) when measured after the anaphylaxis episode/epinephrine dose, consistent with acute cardiac injury. she was then transferred to the medical intensive care unit (micu) for further evaluation and treatment. she was admitted to the micu on [**2107-11-21**]. she was treated for acute lung injury/pulmonary edema, volume-responsive shock, and acute myocardial injury ultimately attributed to her anaphylactoid reaction to iv contrast and subsequent administration of 1 mg iv epinephrine at 1:1000 concentration (note the standard dose of epinephrine for anaphylaxis is 0.3 mg sc/im at 1:1000 concentration). echocardiogram on [**2107-11-22**] demonstrated essentially normal cardiac function. ms [**known lastname 22473**] noted the presence of continous substernal chest discomfort; further evaluation did not demonstrate ekg or enzyme evidence of ongoing cardiac injury. her respiratory status and blood pressure improved with supportive care, and she was transferred from the micu to the medical floor on [**2107-11-22**]. past medical history: # clinically definite multiple sclerosis, relapsing type, onset [**5-/2102**], dx [**2-/2103**] -18 prior attacks -tysabri infusions, [**2106-12-24**] and [**2107-1-24**] -iv methylprednisolone (ivmp) [**2107-1-12**] for flare, then hospitalized one week later for whole body numbness and loss of temperature sense -lhermitte's phenomenon -double vision -urinary retention # migraines # gastroparesis social history: # personal/professional: criminal justice student at [**last name (un) 48848**]in [**location (un) 3844**]. # substance use: no smoking, occasional alcohol, no drug use. family history: noncontributory physical exam: vs (on admission to icu): temp: 97.3 bp: 93/46-->79/46 hr:104 st rr: 36 o2sat 91-94% nrb gen: appears to have moderate increased wob with tachypnea heent: +facial swelling, pupils pinpoint and minimally reactive to light, eomi, anicteric, mmm, op without lesions, no pharyngeal swelling neck: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules resp: course rales anteriorly as well as bilaterally posteriorly cv: sinus tachy, s1 and s2 wnl, no m/r/g appreciated abd: nd, +b/s, soft, no masses or hepatosplenomegaly, left side and low back tender to deep palpation, no rebound/guarding ext: no c/c/e, warm, palpable peripheral pulses skin: no rashes/no jaundice neuro: aaox3. cn ii-xii intact. 5/5 strength throughout. no sensory deficits to light touch appreciated. 2+dtrs-patellar and biceps on left, 1+ rue dtr, hypoactive right patellar dtr. pertinent results: [**2107-11-20**] wbc-5.7# rbc-4.99 hgb-13.3 hct-39.7 mcv-80* mch-26.6* mchc-33.4 rdw-13.0 neuts-54.4 lymphs-36.1 monos-6.7 eos-2.3 basos-0.5 plt count-325 glucose-72 urea n-11 creat-0.6 sodium-137 potassium-3.7 chloride-102 total co2-27 anion gap-12 alt(sgpt)-10 ast(sgot)-20 ck(cpk)-68 alk phos-79 amylase-83 tot bili-0.3 lipase-38 urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin- neg urobilngn-1 ph-5.0 leuk-neg . [**2107-11-21**] abg: po2-88 pco2-39 ph-7.32* total co2-21 base xs--5 wbc-13.9*# rbc-4.58 hgb-12.1 hct-37.0 mcv-81* mch-26.4* mchc-32.7 rdw-13.1 glucose-146* urea n-6 creat-0.5 sodium-138 potassium-3.5 chloride-109* total co2-19* anion gap-14 . cardiac enzymes: troponin peak 0.43 on [**11-21**] at 1:00 am, trended down thereafter. ck-mb peak 16 with mb index 10.6, total cpk 151. . ct abd/pelv: 1. no finding to explain patient's abdominal pain. 2. the patient appears to have experienced a severe anaphylactoid reaction to intravenous contrast, as described in the ""technique"" section of this report. note that this patient had received intravenous contrast as recently as [**2106-12-16**] (for ctpa), uneventfully. . cxr [**11-21**]: impression: right ij tip is seen within the right atrium. recommend withdrawal by at least 2.5 cm. bilateral pulmonary edema. small left effusion. no pneumothorax. mri head: 1. extensive periventricular and subcortical white matter hyperintensities on t2/flair imaging, few of which demonstrate enhancement. probable signal abnormalities involving the middle cerebellar peduncles as well. 2. enhancing lesion in the cervical spinal cord at the c2 level. however, the cervical spine is not completely evaluated on the present study. compared to the prior study with contrast from [**2107-1-16**], though the extent of t2/flair abnormality is stable, all of the enhancing foci are new, suggestive of disease activity. brief hospital course: ms [**known lastname 22473**] is a 20 year-old female with history of multiple sclerosis who presented to the ed with l flank pain and suffered severe anaphylactoid reaction to iv contrast with acute hypoxia and hypotension while undergoing ct scan; in this setting she received 1 mg 1:1000 iv epinephrine and developed acute lung injury/pulmonary edema and acute myocardial injury for which she was transferred to the medical intensive care unit as described above. she was subsequently transferred to the medical floor on [**2107-11-22**]. once transferred to the medical floor, her supplemental oxygen was progressively weaned off. despite persistent symptoms of central chest discomfort following her anaphylactoid event, ekg/enzymes failed to demonstrate ongoing/residual cardiac injury. ms [**known lastname 22473**] noted post-prandial nausea/vomiting for several days s/p her icu stay. she was treated with compazine and zofran with minimal relief. with ongoing symptoms, she received a second dose of compazine on [**11-27**]; approximately four hours later, the patient developed facial contortion and left hand spasm felt likely to represent an acute dystonic reaction to the compazine. she was treated with benadryl, cogentin, and valium. after approximately 8-12 hours, her left hand spasm resolved, however ms [**known lastname 22473**] remained unable to open her jaw from a closed position despite repeated dosing of benadryl, cogentin, and valium. she was seen by the neurology consult service and also by dr [**last name (stitle) 2866**] from oral-maxillofacial surgery. although initially unable to speak because of concurrent inability to move her tongue, after two days her tongue ""loosened"" and she was able to communicate verbally despite persistent jaw closure. it was uncertain whether her inability to open the jaw represented trismus vs alternate complication of her dystonic reaction. ms [**known lastname 22473**] was observed during sleep with persistent closed jaw, arguing against conversion disorder. she was maintained on iv fluid hydration and liquid diet by straw. consideration was given to administration of nerve block to facilitate mechanical manipulation to open the jaw, however on [**12-1**] her jaw was released from the closed position after 10 mg iv valium and mechanical manipulation by her mother - once released, ms [**name (ni) 22473**] was able to independently open/close her jaw, eat, and speak without need for further mechanical intervention. in terms of ms [**known lastname 48849**] original complaint of left flank pain, neurology consult service felt that this most likely represented a thoracic radiculopathy related to a herniated disc. her symptoms persisted, in waxing/[**doctor last name 688**] intensity, throughout her hospital course. on [**12-4**], ms [**known lastname 22473**] notice that her right foot was ""turning in"" (ankle inversion) when she walked; she notes that this is a finding she relates to prior flares of her multiple sclerosis. she also noted ""clumsiness"" of her right hand, most noticeable in her hand-writing which has become less legible, as well as right eye ""blurry vision"". a head mri was obtained which demonstrated new multiple sclerosis disease activity. upon consultation with ms [**known lastname 48849**] primary neurologist, dr [**last name (stitle) 8760**], her scheduled tysabri dose was postponed and she was treated with a 3-day course of intravenous methylprednisolone at a dose of 250mg every 6 hours. her next scheduled tysabri dose was arranged for [**2107-12-12**]. repeat echocardiogram [**2107-12-9**] demonstrated essentially normal cardiac function, without evidence of pericardial effusion or focal wall motion abnormality. medications on admission: tysabri 300 mg/15 ml, 1 iv infusion monthly discharge medications: 1. zovia 1/35e (28) 1-35 mg-mcg tablet sig: one (1) tablet po daily (). 2. ibuprofen 400 mg tablet sig: two (2) tablet po q8h (every 8 hours) as needed for pain. 3. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 4. oxycodone 5 mg tablet sig: two (2) tablet po every 6-8 hours as needed for pain for 1 weeks. disp:*20 tablet(s)* refills:*0* 5. ambien 5 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia: as needed. 6. ondansetron 4 mg tablet every 8 hours as needed for nausea. disp:*10 tablet(s)* refills:*0* 6. ativan 1 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia. disp:*15 tablet(s)* refills:*0* 7. tysabri 300 mg/15 ml, 1 iv infusion monthly as directed by dr [**last name (stitle) 8760**] (neurology) discharge disposition: home discharge diagnosis: primary: 1. anaphylactoid reaction to iv contrast 2. epinephrine overdose. 3. acute lung injury. 4. acute myocardial (heart) injury 4. acute dystonic reaction and prolonged trismus (lock jaw)to prochlorperazine (compazine) 5. left flank pain, likely secondary to thoracic disc herniation 6. multiple sclerosis, relapsing-remitting, with acute flare discharge condition: heart and lung exams have returned to [**location 213**]. face, jaw, and hand spasms, resulting from an adverse reaction to compazine, have resolved. you are being discharged in stable condition, but need close follow-up as an outpatient to ensure full recovery from your complex hospital course. discharge instructions: you were evaluated in the emergency department for left-sided flank pain. you had an abdominal ct scan to evaluate this pain, and had a severe allergic ""anaphylactoid"" reaction to the intravenous contrast used for the ct. you were given a high dose of epinephrine, as well as steroids, famotadine, benadryl, and intravenous fluids for treatment of this reaction. the severe allergic reaction and high dose of epinephrine resulted in injury to your heart and lungs. you were admitted and treated for this reaction in the intensive care unit for 2 days, and once stable, transferred to the medicine floor. you also developed a facial contortion and locked jaw (a dystonic reaction) in response to a medication you took for nausea, called compazine. this resolved initially with medications, except your jaw remained locked for 4 days. you recieved benadryl, benztropine (cogentin), and valium. higher doses of valium in addition to manual manipulation of your jaw was required to finally open the jaw. you developed symptoms of right foot inversion, right hand clumsiness, and right eye ""blurring"". an mri of your head was consistent with an active multiple sclerosis flare. you were treated with high-dose steroids for three days, with mild improvement. please remain at home for 1 week following discharge for further monitoring, given the recent complicated hospital course involving anaphylactic reaction, myocardial injury, acute lung injury, and acute dystonic reaction. your back pain is likely from a bulging disc in your spine. you can treat this with pain medication for now, and if it does not resolve in [**1-17**] weeks, please see your primary care physician to follow it up. please note that you are allergic to iv contrast, and had a dystonic reaction to compazine. these have been added to your allergy list. please return to the ed or call your primary care physician if you have symptoms similar to those you had in the ct scanner - throat tightness, ichiness, or any other concerning symptoms. please do the same if your jaw locks again. followup instructions: you have been scheduled for tysabri infusion at the pheresis unit on at monday [**2107-12-12**] at 2:15 pm. if you have any further questions, please contact your neurologist, dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 8760**], at ([**telephone/fax (1) 11088**] to schedule tysabri infusion. please f/u with your primary care doctor in the next 1-2 weeks to follow up on the multiple issues described above. [**first name11 (name pattern1) 734**] [**last name (namepattern1) 735**] md, [**md number(3) 799**] completed by:[**0-0-0**]",1
58,"admission date: [**2131-1-10**] discharge date: [**2131-2-6**] date of birth: [**2092-12-24**] sex: f service: medicine allergies: latex / adhesive tape attending:[**first name3 (lf) 6169**] chief complaint: doe - hodgkin's lyphoma major surgical or invasive procedure: chest tube placement/vats history of present illness: this is a 38 yo female with nodular sclerosing hodgkin's lymphoma (diagnosed in [**2123**]) that involves her lungs, who presents with worsening respiratory function. she notes that since [**month (only) 216**] she has had increasing doe on exertion and is followed by her oncologist at an osh for this. her dyspnea became worse in [**month (only) **] and she has been unable to lie flat on her back since that time. in [**month (only) 359**] fo [**2129**] she was admitted to osh for pneumonia and treated with abx. her respiratory symptoms continued. she was noted to have a left pleural effusion by x-ray and this was tapped in [**2130-10-26**]. at that time only 200cc of dark fluid was removed (per the patient) and this did not relieve her symptoms at all. more recently in the past two weeks she has been increasingly sob with standing and walking. she notes that she is usually able to breath normally while lying on her side of sitting up in bed, but this has gotten worse in the past week. she does have an occasional productive cough ""when i get excited"" and produces clear sputum. this cough has been present since [**2130-6-26**]. she states that approximately 2 weeks ago she had a low grade temp and was treated for two weeks with avelox (this was stopped on [**1-2**]). the avelox helped her dyspnea for the first week, but her symptoms got worse during the second week of treatment. she also notes that approximately one week ago she developed a gastroenteritis (which she got from her son), and had two days of nausea/vomiting and diarrhea that have resolved. she was seen in clinic today and noted to have doe with walking short distances, rr 40 and hypotension with bps 82/64. her o2 sat was 95% at rest. she is normally seen at an osh and per reports pfts showed fev1 of 0.8 (25% of expected). she was also noted to have a fever, she thinks to 101.0. she was given a 500 cc ns bolus, blood cultures were drawn, and she was treated with vancomycin and ceftriaxone. currently she is sob with speaking but feels better since she has been placed on 4 l nc o2. on ros: she denies n/v, abdominal pain, diarrhea, constipation, rashes, sore throat, dysuria, hematuria, abnormal vaginal discharge. (+) for daily cp midsternal and under right breast (since [**month (only) **] [**2129**]) (+) cough, described above (+) night sweats when she takes vicodin (+) pain in her bones (in her back mostly) for which she takes vcodin past medical history: 1. hodgkin's lymphoma (stage iia, diagnosed in [**2123**] - nodular sclerosing) (see above for details) 2. splenectomy in [**2126**]. 3. h/o herpes zoster. 4. per prior notes has history of fen-phen use. 5. clot in left svc that resulted in swelling of left breast, should be taking coumadin for this but stopped taking it last friday b/c she was upset 6. left pleural effusion oncology history: diagnosed with hodgkin's lymphoma, nodular sclerosing) in [**2123**]. the patient initially was treated with adriamycin, bleomycin, vinblastine, dacarbazine with subsequent disease recurrence. transplant was deferred at that time, and the patient received four cycles of cept. she also received radiation therapy as part of initial treatment for six weeks. she had an autologous bmt in 4/[**2128**]. in [**2-/2130**] (about one year post transplant) a ct evaluation revealed recurrent disease in her chest and abdomen. anterior mediastinal adenopathy was in the field of prior radiation. she underwent a biopsy of her anterior mediastinal adenopathy that revealed recurrent hodgkin's lymphoma. she was then treated with cepp chemotherapy. she had a variable response to cepp and was started most recently on rituxan and vinblastine. social history: the patient is single. she has an 11-year-old son. [**name (ni) **] tobacco or etoh use. she works occasionally in a convenient store. family history: mother passed away from a myocardial infarction. father diagnosed just recently with pancreatic, liver and colon ca (primary ca not known)-also states father has cancer from asbestos physical exam: vs: tc 96.5 hr 145 bp 104/70 o2 sat 98% on 2l gen: young female with dyspnea while talking, but able to speak in full sentances heent: perrl, eomi, anicteric sclera, mmm, clear oropharynx neck: supple, no lad cardio: tachy with reg rhythm, nl s1 s2, no m/r/g pulm: cta b but with decreased breath sounds on left side about halfway up lung with dullness to percussion as well, decrease breath sounds at right lung base abd: soft, nt, +bs, mild tenderness in llq ext: no edema neuro: cn 2-12 intact, muscle strength 5/5 in b/l upper and lower extremities sensation to light touch intact pertinent results: imaging: [**2131-1-10**] cxr - large amount of left pleural fluid which is worse in comparison to the previous study. small amount of right pleural fluid - unchanged in comparison to the previous film. no evidence of pulmonary edema. the patient is status post splenectomy. [**2131-1-11**] chest ct - large left pleural effusion responsible for near-complete collapse of the left lung. small right pleural effusion. minimal pleural nodularity, but no evidence of loculation. extensive prevascular lymphadenopathy extending to and destroying portions of the sternum, left 1st through 3rd anterior ribs, and other left anterior chest wall structures. superior mediastinal lymphadenopathy with mild narrowing of the trachea at the thoracic inlet. no other vital structures compromised. right supraclavicular, paratracheal, subcarinal, paraesophageal, and diaphragmatic lymphadenopathy. [**2131-1-12**] echo - the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. left ventricular systolic function is hyperdynamic (ef>75%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is a trivial/physiologic pericardial effusion. an echo dense mass is noted anterior to the heart/right ventricle outside the pericardial space. [**2131-1-14**] unilateral breast u/s - no fluid collections. [**2131-1-14**] abd u/s - gallbladder sludge. otherwise normal abdominal ultrasound. right pleural effusion. [**2131-1-14**] unilateral l upper ext u/s - abnormal finding in the left internal jugular area likely representing a necrotic lymph node and adjacent patent diminutive internal jugular vein. alternatively, if the patient has had prior procedures or radiation, this may represent chronic fibrosis with focal chronic thrombus. if clinically indicated, this may be further evaluated with a contrast-enhanced neck ct. [**2131-1-16**] cta - no pulmonary embolism. interval improved aeration of the left lung. no consolidation to suggest pneumonia. unchanged bilateral masses and chest wall mass consistent with known metastatic disease [**2131-1-17**] cta - no pulmonary embolism. interval improved aeration of the left lung. no consolidation to suggest pneumonia. unchanged bilateral masses and chest wall mass consistent with known metastatic disease. [**2131-1-20**] cxr - overall stable appearance of the chest with no pneumothorax identified. stable position of the left chest tube. [**2131-1-21**] ct abdomen - marked retroperitoneal and retrocrural lymphadenopathy. two soft tissue density nodules within the mesentery adjacent to the small bowel also likely represent areas of disease involvement. no bowel obstruction. stable appearance of extensive lymphadenopathy within the chest. two millimeter hypodensity within the right posterior segment of the liver, too small to fully characterize. [**2131-1-25**] cxr - bilateral small-to-moderate pleural effusions are again demonstrated with apparent loculation on the left. these appear unchanged in the interval. overall, since the recent radiograph of earlier the same date, there has not been a significant change in the appearance of the chest. [**2131-1-28**] cxr - left subclavian line tip in the superior vena cava is unchanged. there are bilateral pleural effusions left greater than right. there are bibasilar patchy areas of volume loss. hazy increased opacity in the left mid lung corresponds to known mediastinal mass with adjacent chest wall invasion. compared to the film from 2 days ago, the effusions are slightly smaller. [**2131-1-29**] echo - the left atrium is mildly dilated. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). regional left ventricular wall motion is normal. there is a small, echo dense, organized pericardial effusion. compared with the findings of the prior study (images reviewed) of [**2131-1-14**], the small pericardial effusion is more evident on this complete study. [**2131-2-1**] cxr - no interval change in pleural effusions. [**2131-2-5**] cxr - mild pulmonary edema improved since [**1-28**] and 9. contraction of the left hemithorax is longstanding, and left lower lobe atelectasis has been stable since [**1-28**]. small right and moderate left pleural effusion are unchanged. cardiac silhouette is partially obscured by adjacent pleural and parenchymal abnormality but not grossly changed from mild cardiomegaly in the interim. tip of the left subclavian infusion port projects over the svc. no pneumothorax. brief hospital course: 38 yo female with nodular sclerosing hodgkin's lymphoma (diagnosed in [**2123**]) and with disease in her lungs, known left pleural effusion who presented with significant dyspnea on exertion. *hodgkins - the patient has refractery hodgkins disease. she was admitted with known disease relapse and progression. most of her symptoms (pain, dyspnea on exertion, shortness of breath, breast swelling) were all thought secondary to disease infiltration. she was given a cycle of ice chemotherapy. she did have neurotoxicity (confusion, hallucinating) that was thought to be from the ifosfomide so it was held on [**2131-1-25**]; and she only received 25% of her final dose. her final dose of the cycle was on [**2131-1-26**]. she reached her nadir at approximately day 7 and then her counts have slowly started to rise. on discharge her wbc was 1.2 with an anc of 840. she will receive a neupogen shot the day after discharge at the office of dr. [**last name (stitle) 50854**] (arranged by [**doctor first name 8513**]). she will follow up with dr. [**last name (stitle) 50854**] and dr. [**first name (stitle) **] this week. she will likely be readmitted for a second cycle of ice next week. *doe: patient has had progressive doe since [**month (only) 216**]. likely [**12-28**] to underlying hodgkin's disease (some reports of paralyzed left diaphragm), pleural effusion and possible overlying pna. recent pfts done as outpatient showed fev1 of 0.8, which suggested obstructive disease. at admission she was tachypneic and febrile and started on empiric vancomycin and ceftriaxone for possible pneumonia. imaging done here with cxr and chest ct showed diffuse disease in chest and left sided pleural effusion with almost complete collapse of left lung. ip tried to tap the effusion without success, likely b/c it was loculated. pt had vats on [**1-12**] with expansion of lung and placement of two chest tubes and [**doctor last name **] drain. patient had tachypnea and pain post procedure. had o2 sats in low 90s, upper 80s and did not use much o2 because of history of bleomycin exposure. several days after vats the patient had a desat to 77% on ra and was sent to the intesive care unit. she was clinically stable in the icu and did not require intubation. she had a cta to evaluate for pe and was negative. chest tubes were removed. she was transferred back to the floor after 4 days. she remained stable and was treated with morphine pca and fentanly patch for pain control. the chest was left in place to drain for approxmiately 10 days. the patients symptoms were still persistent after the tube was removed. it was felt that the only way to further improve her symptoms was to treat the underlying disease. she was then given a cycle of ice chemotherapy (see above). during the later half of her hospital stay she was intermittently treated with lasix for sob and put on a steroid taper of dexmethasone (on 2mg [**hospital1 **] upon discharge). repeat x-rays showed improving pulmonary edema after lasix treatment. she was discharged on lasix 40mg po at discharge. (multiple echo's showed a normal ef) *h/o left subclavian vein clot: patient had a left subclavian clot several months prior to admission. she took coumadin as an outpatient. her coumadin was held during the early part of her admission because she was scheduled to have a thoracentesis and then vats and required an inr of <1.5 for these procedures. patient did have some swelling of left breast and left upper extremity. ultrasound of left uppper extremity showed: abnormal finding in the left internal jugular area likely representing a necrotic lymph node and adjacent patent diminutive internal jugular vein. alternatively, if the patient had prior procedures or radiation, this could represent chronic fibrosis with focal chronic thrombus. breast ultrasound showed no fluid collections. the hope is that is the chemotherapy shrinks the disease, there will be improvement in the breast and arm swelling. *fevers: patient had a fever a few weeks prior to admission and was treated with avelox at that time. had fever at admission. blood and urine cultures were checked and were negative. cxr showed large left pleural effusion and she was started on ceftriaxone and vancomycin for now for broad spectrum abx coverage to cover for possible pna hidden behind the effusion. she was treated with a 14 day course ([**date range (2) 50855**]) with no further fevers. the patient remained afebrile off antibiotics. *paralyzed vocal cords: patient was found to have hoarse voice and paralyzed vocal cords in the icu. it was unclear if was secondary to vat or her hodgkin's disease affectling the recurrent laryngeal never. a speech and swallow evaluation was done and then a video swallow that showed the patient was not aspirating. her voice was intermittently improved during her hospital course. *anxiety - the patient had continued anxiety and depression throughout her hospital course. she responded well to starting celexa and xanax. she was continued on this regimen at discharge. of note, she had an adverse reaction to iv ativan (hallucinations, confusion). *hypotension: was hypotensive early in admission (sbps in 90s), with no improvement with ivf. had low bps and nl upo throughout her admission, but remained clinically stable. *tachycardia: pt had sinus tachycardia with unclear source. thought to be secondary to infection or dyspnea secondary to collapsed lung. ivfs did not improve tachycardia. medications on admission: synthroid, 100 mcg qd neurontin 300 mg p.o. qam and afternoon neurontin 600 mg qhs vicodin q4-6 hours prn ativan 1 mg p.r.n coumadin 2.5 mg p.o. qod (has not taken since fri) discharge medications: 1. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*3* 2. 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* 3. acyclovir 200 mg capsule sig: two (2) capsule po q8h (every 8 hours). disp:*180 capsule(s)* refills:*2* 4. clotrimazole 10 mg troche sig: one (1) troche mucous membrane qid (4 times a day). disp:*120 troche(s)* refills:*2* 5. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po qod (). disp:*15 tablet(s)* refills:*2* 6. prochlorperazine 10 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for nausea. disp:*30 tablet(s)* refills:*0* 7. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for sleep. disp:*30 tablet(s)* refills:*3* 8. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 9. alprazolam 0.25 mg tablet sig: one (1) tablet po tid (3 times a day) as needed for anxiety. disp:*90 tablet(s)* refills:*0* 10. vicodin es 7.5-750 mg tablet sig: one (1) tablet po every four (4) hours as needed for pain. disp:*90 tablet(s)* refills:*0* 11. morphine 15 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*60 tablet(s)* refills:*0* 12. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 13. dexamethasone 2 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 14. lasix 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: [**hospital1 3894**] health vna discharge diagnosis: hodgkins lymphoma discharge condition: stable; o2 sats in the mid 90's discharge instructions: --please take all medications as prescribed. use your oxygen as needed when you have difficulty breathing. --you will need be closely followed in the outpatient clinic. please make sure to go to all of your appointments. followup instructions: --you have an appointment with dr. [**last name (stitle) 50854**] on thursday ([**2131-2-8**]) at 1:30 pm. you can call [**doctor first name 8513**] ([**telephone/fax (1) 50856**]) if you prefer a morning appointment. --you have an appointment with dr. [**first name (stitle) **] on friday. please go to her office on the [**location (un) 436**] of the [**location (un) 8661**] building at 12:30pm. --you need to have a neupogen shot. i spoke with [**doctor first name 8513**] at dr. [**name (ni) 50857**] office and she said you can come in anytime on wednesday to get the shot.",1
59,"admission date: [**2148-5-8**] discharge date: [**2148-5-26**] date of birth: [**2072-6-27**] sex: f service: medicine allergies: bactrim / shellfish derived / ace inhibitors / levaquin / mirtazapine / ceftriaxone attending:[**first name3 (lf) 10593**] chief complaint: fevers, altered mental status, ? seizures major surgical or invasive procedure: intubation [**2148-5-8**], [**2148-5-13**] extubation [**2148-5-11**], [**2148-5-13**], [**2148-5-20**] direct laryngoscopy, bronchoscopy, left substernal thyroidectomy through cervical approach, with right subtotal thyroidectomy history of present illness: ms. [**known lastname 51035**] is a 75 year old female with a history of seizure disorder who presented from her rehab facility with questionable seizures and fevers. per report, the patient was found yesterday evening by workers at the facility to be aphasic, not responding to commands or questions. at that time the workers thought she was just tired and left her alone. in the morning at change of shift, care takers who were more familiar with the patient's clinical status were concerned she was having a seizure. additionally, at that time temperatures were reocrded at 101.4 at rehab. . in the ed, initial vs were t:100.2/repeat 101.3 and with rectal temp of 104, bp 138/72, hr: 96, rr 20, satting 100% on ra. initally, patient presented not following commands and lethargic. labs were significant for creatinine of 2.0 (baseline 1.5-2.0), glucose to 266, wbc count of 18.3 with 94% pmn's, elevated k+ although labs were hemolysed. phenytoin levels were 12.3. lactate was 3.2 and she received 3 liters of ns, with followup lactate of 2.6. urinalysis was positive for large amounts of wbc's, bacteria, and some rbc's. given her fevers and altered mental status, an lp was performed, and she was empirically provided with vancomycin, ceftraixone, ampicillin, and acyclovir. lp results were was grossly negative for infectious etiologies. cxr did not show gross evidence of pneumonia, and ct head was negative for ich. she had a stat eeg which was nonspecific, and neurology was consulted and will eventually perform a full video eeg. the patient was given 2 mg of iv lorazepam for suspceted fevers. shortly after, oxygen saturations dropped to the low 80's and the patient was intubated for hypoxic respiratory distress. per report, patient was a difficult intubation requring use of a bougie. propofol was used for induction, and after her propofol bolus her blood pressures dropped to the low 80's systolic, but responded with decreases in propofol infusion. upon transfer to the floor, vitals were bp 102/47 hr74 and t101.3 after rectal apap. . on arrival to the micu,patient is intubated and sedated on the vent unresponsive. . review of systems: unable to obtain. past medical history: psychiatric illness paranoid delusions seizure disorder vascular dementia hypertension hyperlipidemia depression chronic kidney disease multinodular goiter history of angioedema gerd hyperthyroidism social history: patient is originally from [**university/college **], no tobacco, no alcohol. she lives in [**hospital3 **] family history: unable to obtain physical exam: on admission to icu: general: intubated and sedated on the vent. not responding to verbal commands. heent: sclera anicteric, mmm, poor dentition. neck: supple, jvp not appreciated, no lad cv: distant hs. regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: coarse breath sounds auscultated anteriorly, but otherwise clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: protuberant. soft, non-tender, hypoactive bowel sounds present, no organomegaly gu: foley in place with no urine (recently drained) ext: cool hands and feet with poor peripheral lower extremity pulses and 1+ radial pulses bilaterally. no edema appreciated. no clubbing. neuro: cannot complete full exam given sedation on vent. laying supine without evidence of decerabrate posturing. pupils are pinpoint and poorly reactive. no blink to corneal irritation. unable to appreciate dtr's in upper extremities or lower extremities. upgoing babinski's bilaterally. . on admission to inpatient medicine: general: alert, disoriented, tangential, speaking spanish, no acute distress heent: perrl 4->3mm bilat, sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, surgical incision intact without erythema, swelling, drainage. jp drain in place with serosanguinous fluid. lungs: clear bilaterally to anterior auscultation, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: midline scar below umbilicus, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley in place with clear yellow urine ext: cool, brisk cap refill, left upper extremity edema, bilat le edema, no clubbing, cyanosis . dicharge physical exam: general: aaox3, speaking in english, no acute distress heent: perrl, sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, surgical incision intact without erythema, swelling, drainage. lungs: clear bilaterally to anterior and posterior auscultation, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: midline scar below umbilicus, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: wwp, brisk cap refill, bilat ue edema l>r, trace bilat le edema, no clubbing, cyanosis pertinent results: admission labs: [**2148-5-8**] 02:15pm blood wbc-18.3*# rbc-3.99* hgb-11.6* hct-38.0 mcv-95 mch-29.0 mchc-30.4* rdw-13.1 plt ct-221 [**2148-5-8**] 02:15pm blood neuts-93.8* lymphs-3.1* monos-1.9* eos-0.9 baso-0.1 [**2148-5-8**] 02:15pm blood pt-11.7 ptt-26.6 inr(pt)-1.1 [**2148-5-8**] 02:15pm blood glucose-266* urean-27* creat-2.0* na-133 k-8.4* cl-99 hco3-25 angap-17 [**2148-5-8**] 08:58pm blood alt-32 ast-33 alkphos-76 totbili-0.3 [**2148-5-8**] 02:15pm blood ctropnt-<0.01 [**2148-5-8**] 02:15pm blood albumin-4.0 [**2148-5-8**] 08:58pm blood albumin-3.3* calcium-9.6 phos-1.1*# mg-1.6 [**2148-5-9**] 05:29am blood tsh-0.62 [**2148-5-9**] 05:29am blood t4-5.4 [**2148-5-10**] 03:52am blood free t4-1.1 [**2148-5-14**] 03:50am blood c4-27 [**2148-5-8**] 02:15pm blood phenyto-12.3 [**2148-5-8**] 04:21pm blood type-art rates-14/ tidal v-500 peep-5 fio2-100 po2-439* pco2-37 ph-7.40 caltco2-24 base xs-0 aado2-243 req o2-48 -assist/con [**2148-5-8**] 02:31pm blood lactate-3.2* k-5.7* [**2148-5-8**] 04:21pm blood o2 sat-97 [**2148-5-9**] 02:09pm blood freeca-1.32 . microbiology data: [**2148-5-8**] urine culture: klebsiella pneumoniae . | ampicillin/sulbactam-- 16 i cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin--------- i gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- 64 i tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s . [**2148-5-8**] 4:55 pm csf;spinal fluid source: lp #3. gram stain (final [**2148-5-8**]): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final [**2148-5-11**]): no growth. viral culture (preliminary): no virus isolated . [**2148-5-8**] 8:59 pm mrsa screen source: nasal swab. **final report [**2148-5-11**]** mrsa screen (final [**2148-5-11**]): no mrsa isolated. . [**2148-5-18**] 12:05 am sputum source: endotracheal. **final report [**2148-5-20**]** gram stain (final [**2148-5-18**]): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final [**2148-5-20**]): rare growth commensal respiratory flora. yeast. rare growth. . [**2148-5-21**] 1:56 am blood culture from cvl line. blood culture, routine (pending): . [**2148-5-21**] 9:55 am blood culture source: line-rij set#2. blood culture, routine (preliminary): staphylococcus, coagulase negative. isolated from only one set in the previous five days. sensitivities performed on request.. aerobic bottle gram stain (final [**2148-5-23**]): reported to and read back by dr. [**last name (stitle) **] [**last name (namepattern4) **] on [**2148-5-23**] at 0105. gram positive cocci in pairs and clusters. . [**2148-5-21**]: urine culture (final [**2148-5-22**]): yeast. 10,000-100,000 organisms/ml.. . radiological studies: ct head - [**2148-5-8**] findings: there is no evidence of intracranial hemorrhage, mass effect, shift of normally midline structures, or vascular territorial infarct. ventricles and sulci are mildly prominent consistent with age-related atrophy. calcifications of the carotid siphons are again noted. no fractures or soft tissue abnormalities are seen. imaged portions of the mastoid air cells and paranasal sinuses appear unremarkable. impression: no evidence of intracranial hemorrhage. . chest xray - [**2148-5-8**] findings: supine ap portable view of the chest was obtained. there has been interval placement of endotracheal tube, terminating approximately 3 cm below the carina. nasogastric tube is seen coursing below the level of the diaphragm and terminating in the expected location of the distal stomach. the aorta is calcified and tortuous. the cardiac silhouette is not enlarged. paratracheal opacity is again seen as also seen on the prior study. subtle medial right base patchy opacity could relate to aspiration. no pleural effusion or pneumothorax is seen. impression: 1. endotracheal and nasogastric tubes in appropriate position. 2. subtle streaky medial right base opacity could relate to aspiration depending on the clinical situation. . right upper extremity ultrasound the left and right subclavian venous waveforms show normal and symmetric tracings with respiratory variability normally noted. the right internal jugular is patent and easily compressible. the axillary and both brachial veins are also easily compressible and fully patent. the basilic vein is patent but the cephalic vein is thrombosed. extensive subcutaneous edema is noted in the arm. conclusion: 1. no evidence of dvt in the right upper extremity. superficial cephalic venous thrombus is noted. . bilateral upper extremity ultrasound findings: [**doctor last name **]-scale and doppler son[**name (ni) 867**] was performed of the bilateral internal jugular, subclavian, axillary, paired brachial, basilic, and cephalic veins. a known superficial venous thrombus in the right cephalic vein is unchanged from [**2148-5-14**] with minimal flow demonstrated on power doppler analysis. the right internal jugular vein contains a small nonocclusive thrombus. a right-sided picc is in position within one of the paired right brachial veins extending into the right subclavian vein, which demonstrates normal compressibility, augmentation and flow. all remaining visualized venous structures in the right upper extremity show normal compressibility, augmentation, and flow. in the left upper extremity, the left internal jugular vein contains a small non-occlusive thrombosis with preserved flow. the remaining visualized venous structures in the left upper extremity show normal compressibility, augmentation and flow. impression: 1. small non-occlusive thrombi in the right internal jugular vein and left internal jugular vein. 2. stable nearly occlusive superficial venous thrombosis of the right cephalic vein from [**2148-5-14**]. . discharge labs: [**2148-5-26**] 05:30am blood wbc-8.8 rbc-2.86* hgb-8.2* hct-27.4* mcv-96 mch-28.8 mchc-30.1* rdw-15.2 plt ct-247 [**2148-5-24**] 04:40am blood neuts-67.4 lymphs-21.8 monos-4.7 eos-5.9* baso-0.1 [**2148-5-26**] 05:30am blood glucose-116* urean-16 creat-1.5* na-144 k-4.0 cl-105 hco3-29 angap-14 [**2148-5-26**] 05:30am blood calcium-8.4 phos-3.5 mg-2.0 [**2148-5-9**] 05:29am blood tsh-0.62 [**2148-5-10**] 03:52am blood free t4-1.1 [**2148-5-9**] 05:29am blood t4-5.4 [**2148-5-23**] 05:59am blood cortsol-18.9 [**2148-5-14**] 03:50am blood c4-27 [**2148-5-26**] 05:30am blood phenyto-11.3 . pending labs: blood cultures from [**2148-5-21**] brief hospital course: ms. [**known lastname 51035**] is a 75 year old female with a history of seizure disorder who presented from her rehab facility with questionable seizures and fevers. . # altered mental status/encephalopathy: pt was initially admitted with unresponsiveness with concern for seizure given her seizure disorder. neurology was consulted and eeg was performed that did not show seizure activity. she was found to have a uti, urine culture grew klebsiella. she was treated with ceftriaxone that was later changed to meropenem given concern for possible angioedema (see below). she was then found to have fungal uti and was started on fluconazole (see below). mental status returned to baseline. she was continued on her home dose of phenytoin then uptitrated as she was subtherapeutic (see below). . # seizure disorder: patient initially presented with concern for seizures. neurology was consulted and eeg did not show seizure activity. patient continued on her home dilantin dose. on [**5-21**] patient had seizure x3. dilantin level was checked and was undectable. patient was reloaded with iv fosphenytoin. patient's home dilantin dose was increased to 125 mg [**hospital1 **]. dilantin level at time of discharge was 14.9 when corrected for hypoalbuminemia. please recheck patient's dilantin dose in three days and adjust dilantin dosing; target dilantin level is 16. . # uti, bacterial, and uti, candidal: pt initially had klebsiella uti treated with meropenem. she had repeat ua after seizure with 150 wbcs. urine culture grew yeast x3. discussed with id, started fluconazole for 10 days. last dose for fluconazole is [**2148-5-31**]. please follow up with a repeat ua at the end of fluconazole course. . # respiratory distress: upon presentation to ed, concern was high for seizure and pt received benzodiazepines. in this setting, she developed hypoxia and required intubation. she required minimal ventilatory support and was able to follow commands without need for much sedation. extubation was attempted on [**2148-5-11**] but she required re-intubation within 3 hours due to respiratory distress. she had a large amount of laryngeal edema that was felt to be responsible for her failed extubation and she was placed on iv steroids to reduce swelling. she had several allergies to antibiotics with adverse reaction being angioedema. given concern that her ceftriaxone may be causing angioedema, she was switched to meropenem. extubation was attempted again on [**2148-5-13**]; she once again developed respiratory distress and hypoxia within 6 hours and required re-intubation. a large amount of edema was again noted. ent was consulted regarding tracheostomy. they recommended ct neck to evaluate size of her large multinodular goiter. they brought her to the or on [**2148-5-17**] for subtotal thyroidectomy and extubation was again performed on [**2148-5-20**]. while in the icu, patient's total body balance was positive 14 liters and crackles were appreciated on lung exam and she had edema of her limbs. patient was given lasix and her edema improved along with her lung exam. please monitor patient's fluid status and respiratory status and give diuretics as needed. extra fluid in her body should mobilize and be excreted in urine. . # s/p subtotal thyroidectomy: pt was noted to have large multinodular goiter. tfts were within normal limits. she had been on methimazole as outpatient; this was not continued in house. ct neck showed large goiter and pt was seen by ent who recommended thyroidectomy as the goiter was compressing her trachea and may have been the reason for her failed extubations. thoracic surgery was also called regarding possible tracheomalacia seen on ct scan. thoracic surgery felt that this was not tracheomalacia but rather compression of trachea from thyroid mass. she underwent thyroidectomy on [**2148-5-17**]. right thyroid lobe was left; parathyroids were left in place. calcium was monitored carefully postoperatively. she had jp drain in place after surgery which was removed. she should follow up with her endocrinologist 3 weeks after discharge and dr. [**last name (stitle) 51039**] to follow up with outcome of surgery. . # volume overload / upper extremity edema: patient's total body fluid balance during her icu stay was positive 14 liters. she required several doses of iv lasix as she developed pulmonary edema. her upper extremities were noted to be swollen (l>r). bilateral upper extremity ultrasound was obtained and showed no-occlussive thrombi in right and left ij. no anti-coagulation was initated as there is no clear evidence of benefit in non-occlussive thrombi. please continue to monitor patient's upper extremities and reevaluate as needed. . # transitional issues: 1) follow up with ent in 2 weeks; must call to schedule appointment 2) follow up with endocrinology in 3 weeks; must call to schedule appointment 3) follow up with pcp regarding this hospitalization 4) recheck dilantin level in 3 days (must correct for hypoalbuminemia) and consider readjusting dosing; target level is 16. 5) notable labs on last check here: hct 27.4, cr 1.5, alt 47, ast 31, phenytoin (dilantin) level 11.3. these can be followed-up after discharge. medications on admission: medications (from rehab) dilantin 100 mg po qhs fluticasone nasal spray 50mcg 1 spray each nostril [**hospital1 **] mucinex 600 mg 1 tab po bid calcium carbonate 600 mg give 1 tab po bid docusate 100 mg po bid metorpolol tartrate 75 mg [**hospital1 **] artificial tears 1 drop both eyes tid donepezil 5 mg qhs combivent nebs 5 times a day prn vitamin d2 [**numeric identifier 1871**] units po qweek until [**2148-7-2**] vitamin d by mouth 1000 u qday [**2148-7-2**] and on trazodone 25 mg po qhs bisacodyl 10 mg po prn robitussin 10 cc's po q4hrs prn cough apap 500 mg po q6hrs prn discharge medications: 1. acetaminophen [**telephone/fax (1) 1999**] mg po q4h:prn pain or fever max 4g/day 2. albuterol-ipratropium [**1-8**] puff ih q4h:prn wheezing, shortness of breath 3. calcium carbonate 600 mg po bid 4. docusate sodium 100 mg po bid 5. donepezil 5 mg po hs 6. metoprolol tartrate 75 mg po bid 7. phenytoin infatab 125 mg po bid 8. bacitracin ointment 1 appl tp qid 9. fluconazole 100 mg po q24h duration: 10 days last day [**5-31**] 10. multivitamins 1 tab po daily 11. senna 1 tab po bid:prn constipation 12. artificial tears 1-2 drop both eyes tid 13. bisacodyl 10 mg po daily:prn constipation 14. fluticasone propionate nasal 2 spry nu [**hospital1 **] 1 spray each nostril 15. guaifenesin [**5-16**] ml po q4h:prn cough 16. vitamin d 50,000 unit po 1x/week ([**doctor first name **]) until [**2148-7-2**] 17. vitamin d 1000 unit po daily until [**2148-7-2**] discharge disposition: extended care facility: [**hospital3 2558**] - [**location (un) **] discharge diagnosis: primary diagnoses: 1) seizure disorder 2) klebsiella urinary tract infection 3) yeast urinary tract infection 4) non-occlusive thombi in right and left internal jugular veins 5) goiter s/p subtotal thyroidectomy 6) volume overload secondary to aggressive fluid resuscitation . secondary diagnoses: 1) hypertension 2) hyperlipidemia 3) chronic kidney disease 4) gerd discharge condition: alert and oriented to time, place, and person. non-ambulatory. clinically stable and improved. discharge instructions: you were admitted to the medicine service for workup and management of your confusion. your confusion was likely multifactorial as outlined below. . you were given lorazepam because there were concerns of seizures, but eeg monitoring did not reveal any evidence of seizure. as a consequence, your breathing was suppressed and had to be sedated and intubated to help you breath better. after successful removal of your breathing tube, you had a seizure and was found that your dilantin level was subtherapeutic secondary to propofol withdrawal and malabsorption of dilantin due to the tube feed you were receiving while intubated. you received loading doses of dilantin and your maintenance dose was increased to 125mg twice daily from 100mg twice daily. on the day of discharge, your dilantin level adjusted for hypoalbuminemia was 14.9. please have your doctor [**first name (titles) **] [**last name (titles) 2449**] at [**hospital3 2558**] check your dilantin level (must correct for albumin level to get effective dilantin level) in three days and consider adjusting your dilantin dose. the goal dilantin level is 16. . you were found to have a bacterial urinary tract infection. this may have been a large contributor of your confusion. your urine culture grew klebsiella that was resistant to ampicillin/sulbactam, ciprofloxacin, and nitrofurantoin, but sensitive to cefazolin, cefepime, ceftriaxone, and meropenem. you were initially treated with ceftriazone, but showed signs of allergic response and was treated with meropenem. at the end of the course of meropenem, your urine culture grew yeast. therefore, you were started on fluconazole on [**5-22**], which is an anti-fungal antibiotic. the last dose of fluconazole will be on [**5-31**]. . you were noted to have increased swelling of your extremities and crackles in your lungs as a result of aggressive fluid resuscitation in the intensive care unit. you received diuretics to take off fluids until no more crackles were heard in your lungs. after this, your body should be able to mobilize the extra fluid in your body and put out in your urine. you also received ultrasound examination of your upper extremities as there were concerns for blood clots. ultrasound imaging showed non-occlussive blood clots in your right and left internal jugular veins. there is no clear evidence for benefit in treating non-occlussive blood clots. therefore, we did not start anti-coagulation. please follow up with your primary care physician to monitor swelling in your arms and your body's fluid status. . while you were intubated in the medical intensive care unit, there were difficulties removing the breathing tube. this was thought to be secondary to your enlarged thyroid. therefore, a surgery was done to remove part of your thyroid by the ear, nose, and throat surgeons. please continue to use the anti-bacterial ointment until you see the surgeons for followup in two weeks. please call to schedule the followup appointment as described below. followup instructions: 1) please call [**telephone/fax (1) 41**] to schedule a followup appointment in two weeks with dr. [**last name (stitle) **] [**name (stitle) **], md regarding your thyroid surgery. 2) please set up a follow up appointment with your endocrinologist in about 3 weeks. 3) provider: [**name10 (nameis) 1570**],interpret w/lab no check-in [**name10 (nameis) 1570**] intepretation billing date/time:[**2148-6-18**] 9:00 4) provider: [**name10 (nameis) 1571**] function lab phone:[**telephone/fax (1) 609**] date/time:[**2148-6-18**] 9:00 5) provider: [**name10 (nameis) **] scan phone:[**telephone/fax (1) 590**] date/time:[**2148-6-18**] 11:45",1
60,"admission date: [**2172-7-31**] discharge date: [**2172-8-20**] date of birth: [**2095-9-18**] sex: m service: medicine allergies: latex / dilantin attending:[**last name (namepattern1) 9662**] chief complaint: sepsis major surgical or invasive procedure: endotracheal intubation mechanical ventilation central line placement skin biopsy foot biopsy history of present illness: this is a 76 year old gentleman with a history of ischemic cardiomyopathy (ef 20-30, aicd), niddm, ckd, chronic atrial fibrilation (not on coumadin because of prior fall and small head bleed) who is being transferred from the [**hospital3 3583**] icu for sepsis of unclear origin on pressors. current course of events begins when he was admitted to [**hospital1 3325**] back in [**month (only) 205**] for a nonhealing right foot ulcer after failing outpatient course of doxycycline. patient has a history of nonhealing foot ulcers (including 1 on left requiring amputation of left 5th toe in [**2159**]). wound cultures negative but imaging at the time was concerning for osteomyelitis. he was eventually discharged to rehab for 6 weeks of iv vanc/unasyn. he did well during rehab and was ambulatory. only issue which was some mild diarrhea which was c diff negative and a transient skin rash with resolved with topical treatment. less than 24 hours after going home (after completing his course of antibiotics) he returned to the ed with severe malaise, chills, fever and fatigue. on presentation to the osh ed he had a temp of 100.6, was hd stable, o2 sats 96%. labs notable for wbc of 12,000 with 10% bands and [**last name (un) **] with creatinine of 3.1 vs 2.5 the day prior (baseline 1.5-2.5). cxr normal. ua showed 2+ leuk est with 10-20 wbcs, budding yeast, and 1+ bacteria. he did not have an indwelling catheter. he was admitted with possible uti and started on iv cipro. since admission to [**hospital 52510**] hospital he has continued to clinically decline. progressive leukocytosis, fevers up to 104, and worsening [**last name (un) **]. his [**last name (un) **] catheter was removed (tip cultured, routine and fungal cultures still pending as of [**7-31**]). imaging showed evidence of osteomyelitis but overall it appeared his ulcer clinically had improved after extended antibiotics. he developed a progressive diffuse maculopapular rash with associated pruritis. he was transferred to the icu on [**7-29**] for episodic hypotension (to sbps 60s-70s) associated with worsening labs and rash. cipro was stopped and he was started back on vanc/unasyn as well as on iv fluconazole for concerns for systemic fungal infection (recent broad spectrum antibiotics and budding yeast in urine). seen by id (dr. [**name (ni) 52511**]). repeat c diff testing was done which was ultimately negative. hypotension was fluid responsive but after several boluses started neo (due to tachycardia/af/rvr). in the 24 hours prior to transfer (on [**7-31**]) he continued to clinically deteriorate. his antibiotics were changed to daptomycin, aztreonam and voriconazole given concerns for hypersensitivity reaction to prior antibiotics. all urine and blood cultures were negative. while awaiting results of c diff an abdominal ct showed gastric distention without signs of colitis or other intraabdominal source of infection. his diffuse rash persistent. renal was consulted. creatinine continued to rise and he was given further ivf (on home diuretics at baseline for cm). his blood pressures continued to decline and a right ij was placed. initial cvp was 17. he was started on neosynephrine. he continued to have af/rvr. lactate elevated at 2.7. venous saturation 79%. concern raised for aicd infection given progressive course. echo showed ef 25% and no ""obvious sign of infection of cardiac hardware"". no new complaints on the morning of transfer however his labs continued to decline and were notable for a wbc count of 32,000 with 45% bands and a creatinine up to 5.1. lactate unchanged at 2.6. his declining status was discussed with the family and it was decided to transfer him to a tertiary care facility. sbps prior to transfer were in the 60s-70s on neo. he had made only 30cc of urine overnight. during the 24 hours prior to transfer at osh his heart rates have mostly been in 120s, bursts (especially with fevers) to 130s-140s, resolve with treating temperature. on arrival to the micu he was severely ill-appearing and confused. he had no specific complaints but was mumbling words which were unintelligible. within 30 minutes of arrival he reported feeling much better and was alert and oriented to place. review of systems: (+) per hpi (-) denies headache, cough, shortness of breath, chest pain, chest pressure, palpitations, nausea, vomiting, diarrhea, abdominal pain. past medical history: ischemic cardiomyopathy niddm nonhealing foot ulcers af with rvr not on coumadin [**1-16**] prior head bleed ckd baseline 1.5-2.5 cad with prior stent social history: lives at home with wife. quit smoking 25 years ago. quit etoh 30 years ago. worked as a police officer and then baliff. retired in [**2157**]. family history: brother died of mi physical exam: on admission to [**hospital1 18**] vitals: t: 97.2 bp: 81/59 p: 125 rr: o2: 94%/2l general: severely ill-apearing heent: sclera anicteric, mmm, perrl neck: supple, jvp not elevated, no lad cv: tachycardic, no murmurs, rubs, gallops lungs: clear to auscultation anteriorly, no wheezes, rales, ronchi abdomen: soft, obese, mildly diffusely tender, bowel sounds present gu: foley with minimal urine ext: 2+ edema bilaterally, cool, clampy, poorly perfused, palpable pulses bilaterally, left foot eschar, lateral aspect of right foot 5th toe ulcer, deep but without surrounding erythema neuro: alert and oriented to place on discharge: general: nad comfortable heent: sclera anicteric, mmm, perrl neck: supple, jvp not elevated, no lad cv: irregularly irregular, no murmurs, rubs, gallops lungs: clear to auscultation anteriorly, no wheezes, rales, ronchi abdomen: soft, obese, mildly diffusely tender, bowel sounds present, diffusely edematous gu: mildly swollen scrotom, foley with clear yellow urine ext: 2+ edema bilaterally, venous stasis changes, left foot eschar, lateral aspect of right foot 5th toe ulcer neuro: alert and oriented to person, date and place pertinent results: labs on admission to [**hospital1 18**] ============================== [**2172-7-31**] 03:00pm blood wbc-29.9* rbc-3.79* hgb-11.1* hct-35.8* mcv-94 mch-29.3 mchc-31.1 rdw-17.9* plt ct-177 [**2172-7-31**] 03:00pm blood neuts-93.5* lymphs-3.5* monos-1.6* eos-1.2 baso-0.2 [**2172-7-31**] 03:00pm blood pt-13.3* ptt-31.1 inr(pt)-1.2* [**2172-7-31**] 03:00pm blood fibrino-409* [**2172-7-31**] 03:00pm blood glucose-151* urean-88* creat-4.8* na-137 k-5.0 cl-106 hco3-14* angap-22* [**2172-7-31**] 03:00pm blood alt-51* ast-71* ld(ldh)-330* ck(cpk)-1751* totbili-0.3 [**2172-7-31**] 03:00pm blood ck-mb-27* mb indx-1.5 ctropnt-0.08* [**2172-7-31**] 03:00pm blood albumin-3.0* calcium-6.9* phos-5.2* mg-1.8 iron-77 [**2172-7-31**] 03:00pm blood caltibc-127* ferritn-4249* trf-98* [**2172-8-2**] 01:27am blood cortsol-32.6* [**2172-8-1**] 04:08am blood crp-greater th [**2172-7-31**] 03:00pm blood vanco-13.7 [**2172-7-31**] 03:12pm blood lactate-2.7* [**2172-7-31**] 09:03pm blood o2 sat-98 [**2172-7-31**] 03:54pm blood freeca-1.03* labs on discharge from [**hospital1 18**] =============================== [**2172-8-20**] 06:50am blood wbc-4.9 rbc-3.14* hgb-9.0* hct-29.9* mcv-95 mch-28.8 mchc-30.2* rdw-17.8* plt ct-173 [**2172-8-19**] 07:35am blood neuts-83* bands-4 lymphs-2* monos-3 eos-6* baso-0 atyps-0 metas-2* myelos-0 [**2172-8-20**] 06:50am blood glucose-144* urean-49* creat-1.9* na-144 k-4.2 cl-105 hco3-32 angap-11 [**2172-8-19**] 03:30pm blood alt-29 ast-31 alkphos-97 totbili-0.4 [**2172-8-11**] 02:50am blood ck-mb-5 ctropnt-0.08* probnp-[**numeric identifier 52512**]* [**2172-8-20**] 06:50am blood calcium-7.3* phos-2.5* mg-1.9 [**2172-7-31**] 03:00pm blood caltibc-127* ferritn-4249* trf-98* [**2172-8-20**] 04:32am blood type-[**last name (un) **] po2-94 pco2-55* ph-7.40 caltco2-35* base xs-6 studies cxr [**7-31**] ap radiograph of the chest was reviewed with no prior studies available for comparison. cardiomegaly is present, severe. pacemaker defibrillator lead terminates in the right ventricle. the right internal jugular line tip is at the level of superior svc. lungs are essentially clear with no appreciable pleural effusion or pneumothorax. x-ray [**8-1**] impression: possible osteomyelitis at fifth metatarsophalangeal joint. echo [**8-1**] conclusions moderate to severe spontaneous echo contrast is seen in the body of the left atrium. mild spontaneous echo contrast is present in the left atrial appendage. the left atrial appendage emptying velocity is depressed (<0.2m/s). the right atrium is dilated. mild spontaneous echo contrast is seen in the body of the right atrium. a mobile echodensity is seen on the ra portion of the icd lead (best seen on clips 4, 67, and 95). no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is severely depressed (lvef= 20 %). there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. no mass or vegetation is seen on the mitral valve. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate [2+] tricuspid regurgitation is seen. the pulmonary artery systolic pressure could not be determined. impression: mobile echodenisty on the icd lead may be a vegetation, but cannot be distinguished from fibrin formation. no vegetations seen on the mitral, tricuspid, or aortic valves. mild mitral regurgitation. moderate tricuspid regurgitation about the icd lead. severe global left ventricular dysfunction. cxr [**8-1**] impression: low lung volumes, no change since prior chest x-ray. cxr [**8-2**] clinical history: patient intubated for respiratory failure, evaluate position of endotracheal tube. the tip of the endotracheal tube lies 4.8 cm from the carinal angle in a satisfactory position. there has been no significant change since the prior chest x-ray. the heart remains enlarged but failure is not currently present. ct chest/abd/pelvis [**8-4**] impression: 1. no ct evidence for abscess. 2. atrophic kidneys with multiple round lesions which are incompletely evaluated on this study. further evaluation is recommended with non-urgent ultrasound. 3. cholelithiasis without evidence for cholecystitis. 4. arterial atherosclerosis including the coronary arteries as well as aortic valve calcifications of indeterminate hemodynamic significance. 5. calcified right thyroid nodule. if not done recently, further evaluation is recommended with ultrasound. 6. bilateral pleural effusions with adjacent atelectasis. 7. nasogastric tube terminating just below the gastroesophageal junction. advancing the tube is recommended. ultrasound upper extremity [**8-6**] impression: 1. nonocclusive thrombus seen within the internal jugular vein bilaterally. 2. a short segment of the left cephalic vein contains occlusive thrombus. ultrasound lower extremity [**8-6**] impression: no evidence of deep vein thrombosis in either leg. scrotal ultrasound [**8-9**] impression: no evidence of deep vein thrombosis in either leg. ct pelvis [**8-10**] impression: 1. no evidence of scrotal air. soft tissue stranding is noted along the left thigh and anterior abdominal wall subcutaneous tissues. 2. diffuse calcific atherosclerosis. 3. possible thickening of the rectal wall may be evaluated by digital rectal exam. cxr [**8-11**] findings: as compared to the previous radiograph, the pre-existing predominantly basal parenchymal opacity has slightly increased bilaterally. an infectious cause for this opacity is possible. in addition, signs of moderate pulmonary edema are present. persistent blunting of the left costophrenic sinus, caused by a small left pleural effusion. the right picc line has been removed in the interval. there is unchanged evidence of a correctly positioned left pectoral pacemaker. ct head [**8-11**] impression: 1. study limited by artifacts. 2. no acute hemorrhage. 3. large left posterior cerebral artery territory infarction, which appears to be chronic. extensive chronic small vessel ischemic disease in the supratentorial white matter. while no ct evidence of an acute major vascular territory infarction is seen, mri would be more sensitive for an acute infarction, particularly in the setting of extensive chronic changes. ultrasound uppter extremity [**8-14**] impression: 1. new left basilic partially occlusive thrombus adjacent to an existing picc. 2. unchanged non-occlusive thrombus within the left cephalic vein. 3. unchanged small non-occlusive thrombus within the left ij. pathology skin biopsy [**7-31**] specimen submitted: left abdomen procedure date tissue received report date diagnosed by [**2172-7-31**] [**2172-8-1**] [**2172-8-4**] dr. [**last name (stitle) **] [**last name (namepattern4) 12033**]/lo?????? diagnosis: skin, left abdomen: patchy vacuolar interface change, spongiosis with focal subcorneal necrosis, and superficial to mid-dermal perivascular lymphocytic infiltrate with abundant eosinophils (see note). note: no bacteria, fungi or acid fast bacilli are seen on brown-brenn, gms, [**last name (un) 18566**] and afb stains. immunostains for cmv, hsv1 and 2, and vzv are negative. no vasculitis or superficial pustulosis is seen. in the described clinical context, the findings are most suggestive of a systemic hypersensitivity reaction, as to a drug. clinical: specimen submitted: left abdomen. clinical: 76 yr. old male with sepsis and on many antibiotics for past 6 weeks with morbilliform rash. please evaluate for drug hypersensitivity, agep, dress, vasculitis, infectious, toxic erythema. gross: the specimen is received in a formalin filled container labeled with the patient's name ""[**known firstname **] [**initials (namepattern4) **] [**known lastname 52513**]"", medical record number and date of birth. specimen consists of a punch of skin measuring 4.4 cm in diameter excised to a depth of 0.8 cm. the surface of the skin is remarkable for an irregularly-shaped light pink papule measuring 0.3 x 0.3 cm. the margin is inked in blue. the specimen is bisected and entirely submitted in cassette a. brief hospital course: this is a 76 year old gentleman w/ a hitory of cardiomyopathy, af not on coumadin, recurrent nonhealing ulcers and recent osteomyelitis transferred from [**hospital3 **] with severe sepsis w/o definite source. active issues #. shock: the pt was transferred to [**hospital1 18**] micu in shock, likely due to combination -of septic and cardiogenic etiologies. he was treated empirically for sepsis with broad spectrum antibiotics including vancomycin and meropenem for 7 days. weaned off all pressors on [**8-4**]. no source of infection was identified and antibiotics were discontinued on [**8-7**]. he was afebrile and hd stable at the time of transfer to medicine floor. the etiology of his sepsis was not identified. at the time of discharge, pt had been stable off of antibiotics and was afebrile without leukocytosis. # ischemic cardiomyopathy: ef 20-30% on echo ([**8-1**]). a nstemi prior to transfer to [**hospital1 18**] cannot be ruled out given slightly elevated ckmb and troponin. lisinopril, and spironolactone were held. asa and plavix were continued. his statin was restarted. he was given iv lasix for volume overload and responded well to doses of 120 iv. he was put on metoprolol 12.5 mg [**hospital1 **]. his lisinopril and spironolactone were still on hold at the time of discharge because of unstable kidney function. on telemetry, there has been frequent asymptomatic pvc and nsvt. # [**last name (un) **]/ckd: patient developed acute renal failure and required cvvh while in the micu in the setting of hypotension and shock likely related to atn. renal was consulted, his urine sedimentation showed granular casts without muddy brown casts. he was not hyperkalemic, acidotic or uremic. at the time of transfer to medicine floor he did not need further cvvh though he was oligouric making 300cc or urine on the day prior to transfer. in the setting of low free water intake he became hypernatremic with a free water deficit. the hypernatremia and uop improved with diuresis and d5w resuscitation. his creatinine was stable around 2 at time of discharge. # respiratory failure: he was intubated for inadequate compensation for metabolic acidosis/concomitant respiratory acidosis. he was extubated on [**8-5**]. upon transfer to [**hospital1 **] he was breathing well on 3l o2. on the medical floor, he occasionally required 2l nc to maintain his o2 saturation above 90%. he had one night of desaturation into the 70s when sleeping which required transfer to the micu. this was most likely secondary to chronic air trapping with obesity hypoventilation and pulmonary edema as his lasix had been held in the setting of increased diarrhea from cdiff. his oxygenation improved with diuresis and cpap, and he was transferred back to the floor. sleep medicine evaluated the patient who recommended bipap 10/5 when sleeping. # upper extremity non-occlusive thrombi: reported history of cns bleed, according to the pcp, [**name10 (nameis) **] had a spontaneous intracranial hemorrheage. anticoagulation was held given history of spontaneous intracranial hemorrhage. upper extremity us showed multiple ij thrombi and a thrombus at the picc site. picc was d/ced, left arm swelling decreased. vascular was consulted about possible svc filter but recommended against placement at this time. he is scheduled for outpatient vascular follow up. # c. diff: patient was noted to have diarrhea on [**8-15**]. cdiff was positive. he was started on po vancomycin. he remained afebrile without leukocytosis and his diarrhea improved. he was discharged with plans to complete a 14 day course of po vancomycin (last day [**2172-8-29**]). # pusutular drug reaction: the pt developed a body rash at osh, although exact cause of the reaction was unclear. review of discharge medications from life care [**location (un) 3320**] was unrevealing as there were no new medications at the time of discharge. however, it is unclear which meds were given while he was at rehabilitation. he completed a course of clobetasol propionate 0.05% ointment with marked improvement. per dermatology, this is consistent with acute generalized exanthematous pustulosis (agep), a drug reaction, although unclear which medication at the rehab was the culprit. if recurs, will need to follow lft and eos. rash had resolved by discharge. new erythematous blanching rash on abdomen and thighs started on [**8-18**], is stable and likely from irritation. this will need to be monitored at rehab. #. atrial fibrilation with rvr: cardiology was consulted and recommended rate control with metoprolol and continued diuresis. he was maintained on telemetry. he was not anticoagulated for afib as he had hx of spontaneous intracranial bleeding. # osteomyelitis: pt has a history of unhealing ulcers secondary to pvd. amputation was suggested, but declined by the patient in the past. he developed osteomyelitis about 2 months prior to admission, and treated with 6 wk course of vanco/zosyn for right non-healing ulcer. imaging [**7-29**] at osh showed slight worsening vs prior. at [**hospital1 18**], on [**7-31**], plain film of the right foot was concerning for osteomyeltiis involving right #5 metatarsal. esr and crp on [**2172-8-8**] unremarkable. podiatry did a biopsy through the wound, cultures were negative (on antibiotics). podiatry ecommended local wound care, wet to dry dressings, off-loading multipodus boots. weight bearing status: pwbat to right heel. he will need to follow up with podiatry after discharge. # ischemic toes: the pt was noted to have necrotic toes concerning of ischemia in setting of coming off pressors. his non invasive aterial study on [**8-7**] showed monophasic dp on r and triphasic pedal pulses on l. vascular surgery was consulted and felt that observation with follow up as an outpatient was appropriate. # agitation/ams: this occured while pt was on the floor and differential included hypoglycemia vs hypernatremia vs ongoing occult infection. his nighttime insulin dose was decreased. hypernatremia was treated with d5w. respiratory distress also a factor which improved during the day with stimulation and family members. # swollen painful scrotum: concerning for fournier's gangerene, urology consulted and found no evidence of fournier's on u/s or ct. he responded to repositioning. this was likely due to edema from fluid overload. # dm: on glargine and insulin sliding scale. # communication: wife [**name (ni) **] [**telephone/fax (2) 52514**]c [**telephone/fax (2) 52515**]h # code:dnr (but icd active), okay to re-intubate transitional issues: ======================== # code status: dnr (with icd active), ok to intubate # pending studies -blood culture: [**8-10**] x2 - ngtd # medication changes - stopped aldactone - stopped atenolol - stopped allopurinol - stopped ambien - stopped hctz - stopped glyburide - changed metoprolol succinate to tartrate - started lantus and sliding scale insulin - started vancomycin po - started nystatin powder - started calcium carbonate as started - started lidocaine patch #transitional issues -thyroid ultrasound as per ct above -pt has latex allergy -diuresis as tolerated to maximize his volume status (has responded to lasix iv 120 mg boluses) -electrolyte monitoring [**hospital1 **] -strict is/os, daily weights -please remove foley -cpap -complete treatment of c.diff (last day is [**8-29**]) -monitor rash on abdomen -physical therapy -wound care site: bilateral feet wounds (r>l) description: -circular ulcer on plantar side of r 5thmtp, no signs of infection-superficial pressure ulcer on l lateral heel care: right foot: wet to dry dressing, change daily.left foot: care per pressure ulcer protocol site: sacral and coccyx skin breakdown description: there is mild maceration and there is a darker area on the left gluteal concerning for possible deep tissue injury. the pt reports pain to the area. the entire area is approx 5 x 7cm. the pt is incontinent of stool and this may be contributing to the skin breakdown - there is no perianal dermatitis or skin breakdown. the skin impairment noted above may be related to pt's drug rash and worsened by incontinence and pressure. care: cleanse skin gently after each bm using aloe vesta foam and soft disposable towelettes avoid rubbing, instead pat tissues gently to avoid increased pain apply thin layers of critic aid across entire perineal and gluteal tissues no need to reapply after each bm, reapply after 3rd cleansing only -needs cardiology follow up for heart failure management -needs vascular follow up for ischemic toes and upper extemity clot -needs sleep follow up for sleep study and management of osa -consider pfts and pulmonary follow up -needs ultrasound of renal masses seen on ct -needs ultrasound of calcified thyroid nodule seen on ct medications on admission: preadmissions medications listed are incomplete and require futher investigation. information was obtained from family/caregiver. 1. furosemide 120 mg po bid 2. glyburide 1.25 mg po daily 3. atenolol 25 mg po daily 4. aspirin 81 mg po daily 5. clopidogrel 75 mg po daily 6. lisinopril 5 mg po daily 7. pravastatin 40 mg po daily 8. albuterol inhaler 1 puff ih q6h:prn wheezing 9. zolpidem tartrate 10 mg po hs:prn insomnia 10. oxycodone-acetaminophen (5mg-325mg) 1 tab po frequency is unknown 11. acetaminophen 650 mg po frequency is unknown 12. allopurinol 300 mg po daily 13. amoxicillin dose is unknown po frequency is unknown as needed for flu symptoms 14. ascorbic acid 1000 mg po daily 15. guaifenesin *nf* 600 mg oral [**hospital1 **]: prn 16. spironolactone 25 mg po daily:prn blood pressure 17. hydrochlorothiazide 25 mg po daily:prn blood pressure 18. metoprolol succinate xl 25 mg po daily preadmissions medications listed are incomplete and require futher investigation. information was obtained from family/caregiver. 1. furosemide 120 mg po bid 2. glyburide 1.25 mg po daily 3. atenolol 25 mg po daily 4. aspirin 81 mg po daily 5. clopidogrel 75 mg po daily 6. lisinopril 5 mg po daily 7. pravastatin 40 mg po daily 8. albuterol inhaler 1 puff ih q6h:prn wheezing 9. zolpidem tartrate 10 mg po hs:prn insomnia 10. oxycodone-acetaminophen (5mg-325mg) 1 tab po frequency is unknown 11. acetaminophen 650 mg po frequency is unknown 12. allopurinol 300 mg po daily 13. amoxicillin dose is unknown po frequency is unknown as needed for flu symptoms 14. ascorbic acid 1000 mg po daily 15. guaifenesin *nf* 600 mg oral [**hospital1 **]: prn 16. spironolactone 25 mg po daily:prn blood pressure 17. hydrochlorothiazide 25 mg po daily:prn blood pressure 18. metoprolol succinate xl 25 mg po daily discharge medications: 1. collagenase ointment 1 appl tp daily please apply to ulcers with dressing changes. 2. docusate sodium (liquid) 100 mg po bid:prn constipation 3. glargine 16 units bedtime insulin sc sliding scale using novolog insulin 4. aspirin 81 mg po daily 5. clopidogrel 75 mg po daily 6. heparin 5000 unit sc tid 7. miconazole powder 2% 1 appl tp qid:prn fungal areas 8. senna 1 tab po bid 9. albuterol inhaler 1 puff ih q6h:prn wheezing 10. ascorbic acid 1000 mg po daily 11. acetaminophen 650 mg po q6h:prn pain 12. pravastatin 40 mg po daily 13. calcium carbonate 1000 mg po qid:prn heartburn 14. vancomycin oral liquid 125 mg po q6h started [**8-16**] 15. sodium chloride nasal [**12-16**] spry nu qid:prn dry nasopharynx 16. lidocaine 5% patch 1 ptch td daily apply lower back/sacrum near area of pain 17. dextrose 50% 12.5 gm iv prn hypoglycemia protocol 18. metoprolol tartrate 12.5 mg po bid hold for sbp<100 hr<60 19. furosemide 120 mg iv bid:prn volume overload 20. glucagon 1 mg im q15min:prn hypoglycemia protocol discharge disposition: extended care facility: [**hospital1 700**] - [**location (un) 701**] discharge diagnosis: primary diagnosis - sepsis - congestive heart failure (systolic, acute on chronic, ef 20-30%) - nonhealing foot ulcer secondary diagnosis - diabetes mellitus - atrial fibrillation - chronic kidney disease - drug rash discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: bedbound. discharge instructions: dear mr. [**known lastname 52513**], it was a pleasure taking care of you at the [**hospital1 771**]. you were transferred from an outside hosiptal with sepsis, which is a serious illness that happens when an infection affects the whole body so your heart had trouble to supply your organs. after aggressive medical management including strong antibiotics, blood pressure medications, respiratory support, cardiovascular support, you were able to recover from the serious illness. the source of your infection was not identified despite our best effort in multiple radiology scans, and labs tests. however, due to your serious condition, a number of your organs have been affected. your kidney was damaged for lack of blood supply. fortunately, it has improved and you did not require dialysis. your toes turned blue because of lack of blood supply. secondly, you came in with a diffuse body rash that we thought was caused by a drug reaction. the drug that might have caused your rash was never identified. your rash improved with a steroid cream. also, in the search of your infection source we found multiple clots in your upper arms where the iv lines previously were placed. you did not have occlusion of your arm vessels. we did not give you blood thinning medications given your adverse reaction to coumadin in the past. you also had an infection of your bowel with a bacteria called clostridium difficile which causes diarrhea. it was treated with oral vancomycin which you will continue until [**2172-8-29**]. you also had trouble breathing which required a transfer to the medical icu for one night. you were placed on cpap breathing machine and given more lasix which improved your symptoms and you were able to come back to the medical floor. you also received intravenous medication to remove fluids from your body. we were able to make some progress. however it appears that this process will take some time. we think that you may benefit from further diuresis in a rehab setting, where more targeted nursing and physical therapy could also be provided. please note that a number of changes have been made to your medications. please follow up with your providers as scheduled. you will need to be seen by cardiology and vascular surgery providers. you should also follow up in the sleep clinic to help manage your sleep apnea. followup instructions: department: vascular surgery when: tuesday [**2172-9-1**] at 10:30 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 we are working on a follow up appointment for your hospitalization in pulmonary sleep medicine. it is recommended you be seen within 1 month of discharge. the office will contact you with the appointment information. if you have not heard within a few business days please call the office at [**telephone/fax (1) 612**]. department: cardiac services when: tuesday [**2172-9-1**] at 2:00 pm with: [**name6 (md) **] [**last name (namepattern4) 6738**], md [**telephone/fax (1) 62**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) **] campus: east best parking: [**hospital ward name 23**] garage completed by:[**2172-8-23**]",1
61,"admission date: [**2113-11-1**] discharge date: [**2113-11-17**] date of birth: [**2069-3-16**] sex: m service: medicine history of present illness: the patient is a 44-year-old gentleman with a history of alcohol abuse and alcohol-induced cirrhosis, atrial fibrillation, and upper gastrointestinal bleed secondary to nonsteroidal antiinflammatory drugs who was admitted to an outside hospital on [**2113-10-25**] with atrial fibrillation and a rapid ventricular response. it was thought at this time that he was in acute alcohol withdrawal. he was treated with diltiazem given by intravenous bolus and by drip for rate control and ativan with withdrawals. he subsequently developed facial edema and airway edema requiring emergent intubation for airway protection. it is unclear at this time what the initial precipitant was for possible angioedema. he also received protonix at one point during hs hospitalization there. the patient was transferred from [**hospital6 2561**] to the [**hospital1 69**] intensive care unit on [**11-2**] for further management. at [**hospital1 69**], the [**hospital 228**] hospital course was significant for group g streptococcus sepsis; possibly from a cellulitic skin source which has been treated with ceftriaxone. he developed hypotension and required a short course of neo-synephrine. his atrial fibrillation with a rapid ventricular response was eventually treated with digoxin with good rate control. he spontaneously converted into a normal sinus rhythm during his hospital course. his intensive care unit course was also notable for delta multiple sclerosis thought to be secondary to hepatic encephalopathy with a minimal response to rectal lactulose. he also developed a left lung collapse secondary to mucous plugging. the patient received bronchoscopy two times with aggressive suctioning on [**11-9**] and [**11-10**] with eventual re-expansion of his left lower lobe. he failed a speech and swallow evaluation after he was extubated on [**2113-11-11**]. he was also noted to have some trouble with his cough and had a hoarse voice after extubation, thought to be residual from his angioedema. past medical history: 1. alcohol abuse with a history of alcohol withdrawal seizures and hallucinosis. 2. atrial fibrillation. 3. upper gastrointestinal bleed thought secondary to nonsteroidal antiinflammatory drug use. 4. chronic back pain. 5. anxiety. 6. alcohol-induced cirrhosis. 7. interatrial septal aneurysms. 8. chronic deep venous thrombosis with collaterals. 9. hepatitis b and hepatitis c negative at outside hospital. medications on transfer: (from intensive care unit) 1. digoxin 0.1 mg by mouth once per day 2. pepcid 20 mg by mouth twice per day. 3. lactulose 300 mg per rectum twice per day. 4. albuterol as needed. 5. miconazole powder. 6. ceftriaxone (day 10 as of [**2113-11-12**]). 7. tylenol. 8. vitamin k times three. allergies: aspirin, diltiazem, and ativan are questioned for anaphylaxis. social history: the patient is homeless. he lives in a shelter. his cousin is his health care proximally, and he has a sister who lives in [**name (ni) 108**] with whom he is not in communication. family history: family history was unknown. physical examination on presentation: on physical examination, vital signs were stable with a temperature of 98.4 degrees fahrenheit, his blood pressure was 92/38, his respiratory rate was 22, and his oxygen saturation was 95% on 2 liters nasal cannula. in general, the patient was a middle-aged gentleman who was alert. he had some garbled speech and was nonsensical at times. he had a hoarse voice. the lungs had rhonchi bilaterally but greater on the right than on the left. he had 1+ pedal edema and proximal muscle wasting. he had some dilated veins of his upper thorax. pertinent laboratory values on presentation: significant laboratory data revealed the patient's platelet count was 42 (which was stable during his hospitalization). his mean cell volume was 101. his chemistry-7 was normal. his inr was 1.7, prothrombin time was 15.9, and partial thromboplastin time was 29.9. pertinent radiology/imaging: an echocardiogram from [**11-2**] showed an ejection fraction of 60% to 70%. no interatrial septal defects. normal left ventricular and right ventricular function. mitral regurgitation of 2+ and 1+ tricuspid regurgitation. trace pericardial effusions. no vegetations were seen on transesophageal echocardiogram. on [**11-3**], a right upper quadrant ultrasound showed an echogenic liver consistent with cirrhosis and a hyperechoic lesion in the posterior right lobe. there was small free fluid around the liver and some cholelithiasis. no ductal dilatation or gallbladder wall thickening was seen on ultrasound. a chest x-ray from [**11-12**] showed a patchy retrocardiac density and a slight increase in atelectasis. on [**11-11**], an upper extremity ultrasound showed a chronic occlusion of right internal jugular with collateralization. acute thrombus about the brachial vein with normal flow through the second brachial vein. concise summary of hospital course by issue/system: in brief, the patient is a 44-year-old gentleman with a history of alcohol abuse, cirrhosis, and a prolonged admission to the medical intensive care unit for alcohol withdrawal, complicated by anaphylaxis to possibly diltiazem versus ativan or protonix, and group b streptococcus sepsis. he also had atrial fibrillation with a rapid ventricular response, hypotension, and mucous plugging. the patient was transferred to the regular medical floor on [**2113-11-12**]. 1. hypoxia issues: the patient's cough continued to improve during his hospital stay. he had no further episodes of desaturations, and he was able to clear his secretions. a chest x-ray on [**11-16**] showed interval improvement of the left lower lobe collapse and consolidation with clear lung fields. 2. delta multiple sclerosis issues: the patient was noted to have some delirium status post his intensive care unit stay. this continued to clear each day and was thought to be multifactorial with an element of hypoxia, hepatic encephalopathy, and alcohol-induced encephalopathy causing his change in mental status. he had a head computed tomography that was negative for any acute bleed or mass; although there was note of a calcification in the left frontoparafalcine region measuring 6 mm in its greatest dimension which was thought to be related to angioma, although of unclear etiology. he also was noted to have mild brain atrophy on a head computed tomography. by the time of discharge, the patient was able to engage in conversation appropriately and follow commands. 3. angioedema issues: since the angioedema was not witnessed during this hospitalization, it was unclear at this time whether he actually had an episode of angioedema. the allergy service was consulted and they suggested that the patient have a re-challenge of ativan an diltiazem as an outpatient. thyroid studies were sent here which showed a normal thyroid-stimulating hormone and a free t4. his c4 level was within normal limits, and his c1 level was an out of hospital study which was still pending. it appeared highly unlikely that the patient developed angioedema secondary to ativan since he has received ativan multiple times in the past without any adverse reactions. 4. group b streptococcus sepsis issues: the patient was to complete a 21-day course of intravenous ceftriaxone as per infectious disease consultation. as of today's dictation, the patient was on day 16/21. all surveillance cultures have been negative thus far. after the patient has completed his course of antibiotics, he should have surveillance cultures drawn as an outpatient. 5. paroxysmal atrial fibrillation issues: the patient is now in a sinus rhythm; although, it appears that he is at high risk for having recurrent atrial fibrillation given that his left atrium was enlarged on an echocardiogram done at this institution. however, given his alcohol abuse and current unsteady gait, the patient was at a high risk for falls. will continue digoxin for rate control for now, and would reconsider whether the patient would be able to be compliant with outpatient anticoagulation. he was not started on any oral anticoagulation during this hospitalization. 6. cirrhosis issues: the patient has thrombocytopenia which was most likely due to cirrhosis and splenic sequestration. he also had an elevated inr which was most likely due to liver failure. the patient has a history of portal vein thrombosis which is currently stable. from an ultrasound done on [**11-15**], there was no reversal of flow noted. it was unclear at this time whether the patient has had an evaluation for varies; however, this should be done as an outpatient. in terms of his hepatic encephalopathy, he was continued on lactulose 30 mg by mouth three times per day with good effect. he should have an outpatient hepatology appointment once his rehabilitation stay has finished. 7. speech and swallow issues: the patient passed a speech and swallow test several days after his medical intensive care unit stay. he was able to tolerate a full diet without any difficulties and no longer had to remain nothing by mouth. he was not longer at risk for aspiration. discharge diagnoses: 1. paroxysmal atrial fibrillation. 2. alcohol withdrawal. 3. cirrhosis. 4. angioedema of unclear etiology. 5. aspiration pneumonia and mucous plugging causing respiratory failure. 6. group b streptococcus sepsis. 7. hepatic encephalopathy. 8. anemia and thrombocytopenia secondary to cirrhosis and alcohol bone marrow suppression. condition at discharge: condition on discharge was stable. discharge status: to a rehabilitation facility. medications on discharge: 1. ceftriaxone 2 g intravenously q.24h. 2. albuterol inhaler as needed. 3. famotidine 20 mg by mouth once per day. 4. digoxin 0.125 mg by mouth once per day. 5. multivitamin one tablet by mouth once per day. 6. lactulose 30 mg by mouth three times per day. discharge instructions/followup: 1. the patient was to have a peripherally inserted central catheter line placed on [**2113-11-17**] to complete his antibiotic course. 2. the patient was to observe a regular diet with aspiration precautions. [**first name11 (name pattern1) **] [**last name (namepattern4) 8037**], m.d. [**md number(2) 8038**] dictated by:[**last name (namepattern1) 218**] medquist36 d: [**2113-11-16**] 19:59 t: [**2113-11-16**] 20:13 job#: [**job number 50268**]",0
62,"admission date: [**2122-9-3**] discharge date: [**2122-9-10**] date of birth: [**2059-1-8**] sex: f service: medicine allergies: percocet / motrin / nsaids / aspirin / dilantin attending:[**first name3 (lf) 30**] chief complaint: altered mental status major surgical or invasive procedure: none. history of present illness: 62yo f w/ a pmh of esrd on hd s/p failed kidney transplant, dvt (associated w/ hd cath), and htn who presents to the ed today after being found on her neighbors stoop confused and apparently topless. history is primarily taken from ems reports as the patient recalls little of the event. apparently she was feeling her usual self when she went to hd today. she remembers the ride home but she states she got off at the wrong street. the next thing she remembers was being evaluated by ems. of note, her fs was apparently 69 in the field but she is not taking insulin currently. no history of incontinence, tongue laceration, injury or loc. it is not clear how long she was unattended prior to being found. she had a similar presentation in [**1-13**] with question of seizure activity but was eventually thought not to be having seizures. also reports blood in her urine last night, and abdominal pain. reports occasionaly missing her medications, but always taking her statin and coumadin. recent change in coumadin from 5 to 7mg. in the ed her vitals were 97.6, 108, 200/100, 100% ra. fs was in 100s on arrival. she received 5mg iv and 100mg po of metoprolol which slowed her rate and lowered her bp to more appropriate levels. she did have episodes of sinus tach up into the 130s during ej placement attempts. however, this resolved prior to transfer. she was evaluated by neurology in the ed who felt that she was primarily encephalopathic without focality but could not rule out a seizure. past medical history: 1. diabetes mellitus.- unclear hx, not on medication, nl [**name (ni) **] 2. end-stage renal disease secondary to diabetes mellitus s/p failed dual kidney transplant 3. hemodialysis. 4. hypertension. 5. hyperlipidemia. 6. thrombosis of bilateral ivj (catheter placement)-- dvt associated with hd catheter rue on anticoagulation 7. svc syndrome [**1-13**], s/p thrombectomy, on anticoagulation, hospitalization complicated by obturator hematoma and required intubation, peg and trach with vap, and questionable seizure 8. currently, in hemodialysis. 9. osteoarthritis. 10. arthritis of the left knee at age nine, treated with acth resulting in secondary [**location (un) **]. 11. rheumatic fever as child 12. afib with rvr past surgical history: 1. kidney transplant in [**2119**]. 2. left arm av fistula for dialysis. 3. removal of remnant of av fistula, left arm. 4. catheter placement for hemodialysis. 5. low back surgery (unspecified) social history: -lives with her nephew [**name (ni) **], but does not know his number -brother is hcp -[**name (ni) 1139**]: 10pkyr [**name2 (ni) 1818**], recently quit but states that she has restarted and smoking 5 cigs per day -denies etoh/illicits family history: mother and sister with diabetic mellitus. kidney failure in mother, sister physical exam: vs: 96.7, 155/84, 83, 20, 98%ra gen: well appearing, nad heent: ncat, eomi, perrl, oropharynx clear and without erythema or exudate neck: supple, no lad, no appreciable jvd cv: rrr, normal s1s2, systolic murmur at lower sternal border, no rubs or gallops, 2+ pulses pulm: ctab, no w/r/r, good air movement bilaterally abd: soft, nd, mild suprapubic tenderness without rebound or guarding, normoactive bowel sounds, no organomegaly, no abdominal bruit appreciated ext: warm and well perfused, full and symmetric distal pulses, no pedal edema neuro: aox2, trouble with date. memory [**1-8**] at 2min. language fluent. strength 5/5 in all extremities. sensation intact to light touch diffusely. dtrs 2+ bilaterally in patella and biceps, toes down going. gait deferred. seems confused about her history pertinent results: [**2122-9-3**] 01:50pm blood wbc-8.7 rbc-3.84*# hgb-12.5# hct-37.0 mcv-96 mch-32.5* mchc-33.8 rdw-15.5 plt ct-254# [**2122-9-10**] 07:59am blood wbc-9.2 rbc-4.33 hgb-14.1 hct-42.7 mcv-99* mch-32.5* mchc-33.0 rdw-15.4 plt ct-451* [**2122-9-3**] 02:46pm blood pt-17.1* ptt-28.0 inr(pt)-1.6* [**2122-9-10**] 07:59am blood pt-22.3* inr(pt)-2.1* [**2122-9-3**] 01:50pm blood glucose-88 urean-15 creat-4.9* na-140 k-3.9 cl-97 hco3-28 angap-19 [**2122-9-8**] 07:45am blood glucose-88 urean-60* creat-12.2*# na-139 k-4.0 cl-97 hco3-22 angap-24 [**2122-9-10**] 07:59am blood glucose-199* urean-47* creat-9.7*# na-139 k-4.0 cl-92* hco3-26 angap-25* [**2122-9-3**] 01:50pm blood alt-13 ast-16 alkphos-58 totbili-0.5 [**2122-9-3**] 01:50pm blood calcium-10.1 phos-3.8 mg-1.9 [**2122-9-10**] 07:59am blood calcium-9.7 phos-7.0* mg-2.3 [**2122-9-7**] 07:30am blood vitb12-1032* folate-greater th [**2122-9-7**] 07:30am blood tsh-1.2 [**2122-9-4**] 05:40am blood pth-401* [**2122-9-3**] 01:50pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg [**2122-9-3**] 07:30pm urine color-yellow appear-clear sp [**last name (un) **]-1.005 [**2122-9-3**] 07:30pm urine blood-mod nitrite-neg protein-30 glucose-250 ketone-neg bilirub-neg urobiln-neg ph-8.0 leuks-neg [**2122-9-3**] 07:30pm urine rbc-0-2 wbc-[**6-16**]* bacteri-few yeast-none epi-[**11-26**] [**2122-9-4**] 01:30am urine bnzodzp-neg barbitr-neg opiates-pos cocaine-neg amphetm-neg mthdone-neg urine cx ([**9-3**], [**9-4**], [**9-6**]): mixed flora consistent with contamination blood cx ([**9-4**]): 2 negative, 1 ngtd cdiff ([**9-6**]): negative cxr [**2122-9-3**]: impression: no evidence of acute cardiopulmonary process head ct without contrast [**2122-9-3**]: impression: no hemorrhage or acute edema. eeg [**2122-9-4**]: impression: this is an abnormal routine eeg due to the slow background, generalized bursts of slow activity, and multifocal slow transients with triphasic features. these findings suggest a widespread encephalopathy afecting both cortical and subcortical structures. medications, metabolic disturbancies and infections are among the most common causes. there were no lateralized or epileptiform features noted. abdominal ct with contrast [**2122-9-4**]: impression: no evidence of abdominal inflammatory process, or other specific ct finding to explain abdominal pain. head ct without contrast [**2122-9-6**]: (prelim) limited study, despite being repeated, no acute intracranial hemorrhage appreciated. mri head without contrast [**2122-9-7**]: conclusion: no definite interval change in the appearance of the brain compared to the prior study. brief hospital course: 1) altered mental status: pt with similar presentations in the past. labs to evaluate for a toxic-metabolic cause were unrevealing. she was initially treated with cipro for a suspected uti, but stopped on day 2 as this drug can lower the seizure threshold and urine grew mixed flora. head imaging with ct and mri was unrevealing. eeg showed generalized slowing. on the morning of [**9-5**] during her hd treatment, she became very agitated, confused, and then unresponsive. her arms were clutched to her chest in fists and her eyes were deviated to the left. she was given 1 mg of ativan and remained disoriented and somnolent, presumably postictal. of note, she was also dialyzed earlier on the day of admission. neurology was consulted and felt her presentation was due to fluid and electrolyte shifts with hd and recommended [**date range 13401**] for her apparent seizure. dilantin was avoided due to prior drug related angioedema. she remained confused and agitated, and her somnolence increased. she was vomiting and minimally responsive to sternal rub. she was transferred to the micu for observation, received iv haldol for agitation, and was called out the next day as she remained stable. she subsequently received hd two more times with no adverse reaction. her mental status improved and she was a&ox3 at discharge, although likely with some chronic cognitive deficits. her sertraline was held during this admission as well as on discharge, and can be addressed as an outpatient. 2) esrd on hd: she was continued on her tu/th/sat hd schedule. she was continued on nephrocaps and cinacalcet and started on sevelamer. 3) history of dvt/svc syndrome: her inr was initially subtherapeutic at 1.6 and she was bridged on a heparin drip. with warfarin 5mg daily, it improved to 1.9. however, her heparin and warfarin were held when her mental status deteriorated. once ct head showed no bleed, her heparin was continued. when decision was made to not perform lp, her warfarin was restarted and heparin was stopped due to a therapeutic inr of 2.2. medications on admission: atorvastatin - 20 mg by mouth once a day b complex-vitamin c-folic acid 1 capsule(s) by mouth once a day cinacalcet 90 mg by mouthonce a day darbepoetin alfa in polysorbat - 40 mcg/ml solution - once per week weekly lisinopril - 5 mg by mouth daily metoprolol tartrate - 100 mg by mouth daily sertraline 100 mg by mouth hs warfarin - - 7 mg by mouth once a day tylenol 3 prn pain discharge medications: 1. levetiracetam 250 mg tablet [**date range **]: one (1) tablet po qhd (each hemodialysis). disp:*12 tablet(s)* refills:*2* 2. metoprolol tartrate 50 mg tablet [**date range **]: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* 3. b complex-vitamin c-folic acid 1 mg capsule [**date range **]: one (1) cap po daily (daily). 4. atorvastatin 20 mg tablet [**date range **]: one (1) tablet po daily (daily). 5. darbepoetin alfa in polysorbat 40 mcg/0.4 ml pen injector [**date range **]: one (1) subcutaneous once a week. 6. lisinopril 5 mg tablet [**date range **]: one (1) tablet po daily (daily). 7. levetiracetam 250 mg tablet [**date range **]: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 8. sevelamer hcl 800 mg tablet [**date range **]: one (1) tablet po tid w/meals (3 times a day with meals): take with meals. disp:*90 tablet(s)* refills:*2* 9. cinacalcet 90 mg tablet [**date range **]: one (1) tablet po once a day. 10. warfarin 5 mg tablet [**date range **]: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 11. warfarin 2 mg tablet [**date range **]: one (1) tablet po once a day: take at same time as 5mg pill. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: caregroup discharge diagnosis: primary: altered mental status, seizure history secondary: end stage renal disease, status post renal transplant discharge condition: stable. discharge instructions: you were admitted to [**hospital1 18**] with confusion. this occurred after your dialysis. it is possible that you had a seizure during your confusion. it is not clear what caused the confusion, but it has improved greatly, with no problems after your last dialysis. please take all medications as prescribed and go to all follow up appointments. we are holding your sertraline (zoloft) for now as this might have contributed to your confusion. we have started you on [**last name (lf) **], [**first name3 (lf) **] antiseizure medication, with assistance from the neurologists. we are also starting sevelamer, a medication to help your electrolytes. note that you should take your metoprolol twice daily. if you experience any confusion, seizures, weakness, fevers, or any other concerning symptoms, please seek medical attention or come to the er immediately. followup instructions: primary care: dr. [**last name (stitle) **], ([**telephone/fax (1) 45314**], wed [**9-16**], 1pm provider: [**first name11 (name pattern1) **] [**last name (namepattern4) 1330**], md phone:[**telephone/fax (1) 673**] date/time:[**2122-10-16**] 2:00 provider: [**name initial (nameis) 1220**]. [**name5 (ptitle) 540**] & [**doctor last name **], neurology phone:[**telephone/fax (1) 44**] date/time:[**2122-11-10**] 4:30 completed by:[**2122-9-10**]",0
63,"admission date: [**2195-12-29**] discharge date: [**2196-1-22**] date of birth: [**2117-2-10**] sex: f service: surgery allergies: penicillins attending:[**first name3 (lf) 6346**] chief complaint: resp distress, copd, rapid atrial fibrillation major surgical or invasive procedure: exploratory laparotomy, right colectomy and wash out, ileal transverse anastomosis central line placement arterial line history of present illness: 78 yo female with copd, afib on coumadin, chf presents with 2-3 day history of sob, cough, and chest congestion along with some fever and chills and decrease po appetite. denies any other associated symptoms and did receive the flu shot couple of weeks ago. in the ed, patient did not get her ca channel and b blocker and so went into rapid afib with rvr and so being ruled out. had some ekg changes. back to normal rate after meds. past medical history: pmhx: 1. chronic afib 2. htn 3. copd 4. chf (dx'd in setting of rvr) 5. mibi [**7-4**]: negative 6. tte [**5-3**]: 55%, 2+mr social history: long, heavy smoking history. quit 9 years ago. no etoh, drugs. lives at home alone retired lawyer family history: nc physical exam: 100.0 71 113/88 18 96% ra gen: nad, sleeping but easily arousable heent: perrl, eomi neck: no jvd cv: irreg, irreg, no m/r/g lungs: expiratory wheezes abd: soft, nt/nd, nabs ext: warm, no edema pertinent results: [**2195-12-28**] 08:44pm glucose-110* urea n-18 creat-1.3* sodium-140 potassium-3.1* chloride-96 total co2-30* anion gap-17 [**2195-12-28**] 08:44pm pt-20.6* ptt-42.0* inr(pt)-2.7 [**2195-12-28**] 08:44pm plt count-162 [**2195-12-28**] 08:44pm neuts-75.1* lymphs-16.5* monos-8.0 eos-0.1 basos-0.3 [**2195-12-28**] 08:44pm wbc-6.6 rbc-5.09 hgb-15.3 hct-45.9 mcv-90 mch-30.2 mchc-33.4 rdw-14.4 [**2195-12-28**] 08:44pm ck-mb-2 ctropnt-<0.01 [**2195-12-28**] 08:44pm glucose-110* urea n-18 creat-1.3* sodium-140 potassium-3.1* chloride-96 total co2-30* anion gap-17 [**2195-12-29**] 03:50am ck-mb-2 [**2195-12-29**] 03:50am ctropnt-<0.01 [**2195-12-29**] 03:50am ck(cpk)-115 [**2196-1-20**] 07:40am blood wbc-9.3 rbc-3.52* hgb-10.9* hct-32.8* mcv-93 mch-31.0 mchc-33.2 rdw-16.5* plt ct-176 [**2196-1-12**] 01:10pm blood neuts-91* bands-2 lymphs-3* monos-3 eos-0 baso-0 atyps-0 metas-0 myelos-0 hyperse-1* [**2196-1-22**] 07:55am blood pt-13.0 inr(pt)-1.1 [**2196-1-22**] 07:55am blood glucose-121* urean-31* creat-0.7 na-140 k-4.0 cl-99 hco3-34* angap-11 [**2196-1-22**] 07:55am blood calcium-8.1* phos-3.6 mg-2.1 [**2196-1-19**] 09:00am blood vanco-32.0 [**2196-1-19**] 04:48am blood vanco-20.5* [**2196-1-17**] 07:47am blood vanco-30.1 [**2196-1-17**] 05:04am blood vanco-18.5* brief hospital course: the [**hospital 228**] hospital course was significant for the following issues: in the emergency department, the patient's ekg revealed atrial fibrillation at a rate of 127 with 2.5mm st depressions in leads v3-v5, ii, avf. given the patient's history, she was placed on droplet precautions and a nasopharyngeal aspirate was performed to evaluate for influenza. her ekg changes were attributed to demand ischemia in the setting of a rapid rate. she was continued on metoprolol and diltiazem. on hospital day #2, the patient's heart rate increased to the 160s and she became increasingly short of breath and developed significant respiratory distress. an arterial blood gas was performed and revealed: 7.15/88/125. the patient was placed on mask ventilation and transferred to the intensive care unit where she was intubated. micu course: *respiratory failure: the patient's respiratory failure was likely secondary to influenza, copd exacerbation and flash pulmonary edema due to af with rapid ventricular rate. the patient had a direct influenza a antigen test which was positive for influenza a viral antigen. the viral culture revealed hemadsorption positive virus. she was treated with amantadine for a total of 5 days. the patient was treated aggressively for copd flare with solu-medrol and frequent nebulizer treatments. she was transitioned to 60mg po prednisone on [**2196-1-8**]. this should be tapered slowly over the course of [**2-4**] weeks as tolerated. the patient developed a new cxr opacity while in the micu and was treated for a superimposed bacterial pneumonia with vancomycin and levofloxacin. the patient developed a rash on her trunk and extremities. the etiology of rash was not clear but the possibility that this was an adverse reaction to vancomycin or levaquin has been entertained. skin eruption responded to benadryl iv and resolved by the time of transfer out of the micu after abx were discontinued. she completed a course of levofloxacin. the patient was extubated on [**2196-1-7**] and o2 was weaned. *af with rvr: the patient was initially started on a diltiazem drip but continued to require boluses of iv metoprolol with sub-optimal rate control. she was loaded with digoxin on [**1-6**] and continued on digoxin. her rate did decrease somewhat with this regimen. her coumadin was continued initially but then held for elevated inr likely from coumadin interaction with levofloxacin. *hypotension: the patient was transiently hypotensive in the micu and required pressor support and multiple ivf boluses. with treatment of her infection and weaning of sedation, the patient's blood pressure normalized. *colonic pseudo-obstruction: the patient had severe constipation while in the icu likely secondary to fentanyl effect on intestinal motility. she was given neostigmine with good result and then was continued on an aggressive bowel regimen and reglan. *hyperglycemia: the patient was started on an insulin gtt for tight glucose control. she was transitioned to a regular insulin sliding scale prior to transfer from the micu. *fen: the patient was started on tube feeds while intubated. after extubation, she underwent a swallowing study which revealed no signs of aspiration but swallowing was a respiratory demand for her and she could easily desat if feed to quickly. recommendations included: 1. diet of thin liquids and pureed solids. straws are okay. 2. please feed slowly with rest between bites/sips trying to keep sats in low 90's. pt was transferred to medical floor on [**2196-1-9**]. the remainder of her hospital course was significant for the following issues. af with rvr: the patient was transitioned to po diltiazem, metoprolol and digoxin. the patient's rate was consistently in the 105-120 range with occasional bursts to 150-160. she was asymptomatic and hemodynamically stable. she will need to follow up with cardiology as an outpatient and it might be worth consider whether she is a candidate for av node ablation with pm placement. the patient's inr was elevated upon transfer from the micu. this elevation was thought to be due to interaction of coumadin and levofloxacin. the patient's coumadin was held and should continue to be held until her inr reaches goal of [**2-4**]. chf: the patient has a known ef of 50%. she had some evidence of diastolic dysfunction. she was total body overloaded (> 10 liter positive) upon transfer from the micu but diuresed well with lasix. she will need continued diuresis of 750-1l of fluid per day until euvolemic. copd: she was transitioned to 60mg po prednisone on [**2196-1-8**]. this should be tapered slowly over the course of [**2-4**] weeks as tolerated. colonic pseudo-obstruction: the patient was continued on reglan and an aggressive bowel regimen. she had several bowel movements and her abdominal distention was improving. hyperglycemia: continued on riss fen: prior to discharge, speech and swallow were re-consulted for evaluation oral candidiasis: the patient received nystatin for mild oral thrush. [**1-12**] patient taken to or diagnosis: perforated cecum with ileal necrosis with feculent perforation secondary to cecal necrosis secondary to dilatation with ischemia. procedure: exploratory laparotomy, right colectomy and wash out, ileal transverse ileocolostomy. there were no complications and patient was extubated without trouble. ebl 100cc post operatively she was kept npo, ivf, ng, foley, vanc, levo, flagyl pod 1 pain was well controlled. physical therapy was consulted. pod 2 she continued to do well and the ng was taken out. in the evening she felt worse and had one episode of emesis, so a ng was placed again. pod 3 the patient felt better again. cardiology continued to follow. pod 5 she was started on clears. pod 7 she was started on a regular diet. +flatus foley was placed secondary to retension. pod 8 foley was taken out at midnight. pod 9 patient was discharged in good condition to rehab. tolerating a regular diet and moving her bowels without difficulty medications on admission: see below discharge medications: 1. fluticasone propionate 110 mcg/actuation aerosol sig: six (6) puff inhalation [**hospital1 **] (2 times a day). 2. levalbuterol hcl 0.63 mg/3 ml solution sig: one (1) ml inhalation q6h (every 6 hours). 3. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day). 4. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 5. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 6. diltiazem hcl 60 mg tablet sig: two (2) tablet po tid (3 times a day). 7. furosemide 40 mg tablet sig: one (1) tablet po bid (2 times a day). 8. prednisone 5 mg tablet sig: 0.5 tablet po bid (2 times a day) for 3 days: [**1-22**] is first day. 9. prednisone 5 mg tablet sig: 0.5 tablet po daily (daily) for 3 days. 10. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 11. terazosin hcl 2 mg capsule sig: one (1) capsule po hs (at bedtime). 12. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every 8 hours) as needed for pain control. 13. warfarin sodium 2 mg tablet sig: one (1) tablet po once (once) as needed for atrial fibrillation for 1 doses. 14. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 15. bisacodyl 10 mg suppository sig: one (1) suppository rectal daily (daily) as needed. 16. dolasetron mesylate 12.5 mg iv q8h:prn 17. metronidazole in nacl (iso-os) 500 mg/100 ml piggyback sig: one (1) intravenous q8 for 4 days. 18. levofloxacin in d5w 500 mg/100 ml piggyback sig: one (1) intravenous once a day for 4 days. discharge disposition: extended care facility: [**hospital3 7**] & rehab center - [**hospital1 8**] discharge diagnosis: perforated cecum with feculent perforation secondary to cecal necrosis secondary to dilatation with ischemia. chronic obstructive pulmonary disease influenza a bacterial pneumonia atrial fibrillation ileus hyperglycemia oral thrush diastolic heart failure discharge condition: good discharge instructions: 1. please monitor for the following: fever, chills, nausea, vomiting, inability to tolerate food/drink. if any of these occur, please contact your physician [**name initial (pre) 2227**]. 2. staples need to come out in about two weeks. followup instructions: please call dr.[**name (ni) 11471**] office for a follow up appointment. ([**telephone/fax (1) 6347**] follow up with dr. [**last name (stitle) 931**] within 1-2 weeks. follow up with dr. [**first name4 (namepattern1) **] [**last name (namepattern1) 5543**]. call for appointment. completed by:[**2196-1-22**]",1
64,"admission date: [**2102-1-2**] discharge date: [**2102-1-27**] date of birth: [**2041-6-11**] sex: f service: this is a continuation of prior discharge summary for patient's course in the intensive care unit. hospital course: 1. pulmonary: on [**1-2**] the patient developed worsening respiratory distress with tachypnea and hypoxia. she also had a temperature of 105 and chest x-ray revealed bilateral diffuse infiltrates. she had worsening respiratory distress with continued hypoxia, which required intubation and transferred to the intensive care unit. in the intensive care unit she had a very complicated course from a respiratory standpoint. she has a clinical diagnosis of adult respiratory distress syndrome with diffuse bilateral alveolar infiltrates and low po2. she required extremely high peeps up to the mid 20s to adequately oxygenate her. the ______________ was unclear and ________ multifactorial. the most likely culprit was a hypersensitive reaction to numerous antibiotics, which the patient received in the past. she was maintained on the ___________ protocol with low tidal volumes with high respiratory rate and in about three weeks we able to wean off her peep slowly. the patient slowly improved and was able to transition to pressure support ventilation and eventually extubated about four weeks off intubation without any problems. 2. infectious disease: the patient had a complicated course of antibiotics with multiple side effects. she is believed to have adverse reactions to meropenem, levofloxacin, penicillins, and cephalosporins. those side reactions include a rash, high fevers, as well as hypersensitivity reaction that may have been contributing to her adult respiratory distress syndrome. in the beginning of her intensive care unit course she had no significant infections. toward the middle of her intensive care unit course she developed a ventilator associated pneumonia and grew enterobacter cloacae, which was gram sensitive and was being treated with gentamycin. about a week prior to discharge from the intensive care unit she developed _______________ staph line infection. the central line was discontinued. one day prior to leaving the intensive care unit she developed a gram positive cocci bacteremia with 4 out of 4 blood cultures positive for gram positive cocci. she is currently on vancomycin for gram positive cocci bacteremia and gentamycin for enterobacter cloacae __________ associated pneumonia. 3. vitamin insufficiency: upon arrival to intensive care unit the patient failed cord stim test and was therefore started on hydrocortisone for seven days. upon completion of the course hydrocortisone was stopped when she developed hypotension following that and required restarting of the hydrocortisone. the decision was made to continue steroids until she clinical improves and given that she is now doing much better she will have the steroids weaned. 4. hypotensive: the patient remained hypotensive for a considerable period of time. this was believed to be secondary to a possible infection even though none was documented in the beginning or a part of her hypersensitivity reaction to numerous medications. she required pressors for about two to three weeks, but those subsequently weaned off without any difficulty. adrenal insufficiency was another etiology that may have contributed to her hypotension. 5. aml: the patient believed in remission during intensive care unit stay. no blast on peripheral smears. unable to perform bone marrow biopsy secondary to current illnesses. she had transient leukocytosis during her hospital stay. this was believed to be secondary to stress reaction, leukemoid reaction and oral steroid doses. 6. elevated liver function tests: the patient had elevated transaminase, which remained persistent, though relatively stable. we followed those about every other day and showed no significant change. 7. volume overload: the patient received about 20 liters of fluid in the context of initial hypotension believed to be part of multiple septic picture. she became significantly volume overloaded. echocardiogram showed no ef. she was able to diurese on herself and with the help of diuretics. discharge condition: the patient is awake and alert, but significantly decondition from prolonged intensive care unit course. discharge status: discharged to bmt floor. discharge diagnoses: 1. adult respiratory distress syndrome. 2. hypersensitive reaction to multiple antibiotics. 3. enterobacter cloacae. 4. ventilator associated pneumonia. 5. staph epidermis line sepsis. 6. gram positive cocci bacteremia. 7. adrenal insufficiency secondary to possible sepsis. 8. aml. [**first name4 (namepattern1) **] [**last name (namepattern1) **], m.d. [**md number(1) 4561**] dictated by:[**name8 (md) 5094**] medquist36 d: [**2102-1-27**] 12:32 t: [**2102-1-27**] 12:38 job#: [**job number 52692**]",1
65,"admission date: [**2185-11-9**] discharge date: [**2159-2-26**] date of birth: [**2114-7-16**] sex: f service: ccu chief complaint: bilateral hematomas, post cardiac catheterization and electrophysiologic ablation. history of present illness: the patient is a 71 year old female with a history of aortic stenosis, transferred to [**hospital1 1444**] for workup new onset atrial fibrillation and cardiomyopathy. the patient had been experiencing increased shortness of breath at rest and orthopnea for seven days prior to admission. four days prior to admission, she went to [**hospital3 **] hospital and was found to be in atrial flutter. she was also found to have cardiomyopathy with an ejection fraction of approximately 20 to 25%. she was transferred to [**hospital1 188**] per request of her daughter who was a nurse here and had a cardiac catheterization to rule out ischemia. her cardiac catheterization showed an ejection fraction of 25% and aortic valve area of 0.9. the patient had a transthoracic echocardiogram to rule out clot and then was taken to the electrophysiology laboratory for atrial flutter ablation. the patient returned from these procedures with bilateral groin hematomas. she had hypotension with a systolic blood pressure of 78 during the electrophysiologic procedure and was fluid resuscitated. past medical history: 1. pedal edema. 2. mild hypertension. 3. aortic stenosis. 4. hypercholesterolemia. 5. status post right knee replacement. 6. status post abdominal hernia repair. medications on admission: 1. lovenox 100 mg subcutaneous twice a day which was discontinued prior to the day of the procedures. 2. coreg 3.125 mg p.o. twice a day. 3. digoxin 0.25 mg p.o. once daily. 4. lasix 20 mg p.o. once daily. 5. magnesium gluconate 500 mg p.o. twice a day. 6. potassium chloride 40 meq p.o. twice a day. 7. accuretic which is the only medication she was on prior to her hospitalization at [**hospital3 **] and she had been on accuretic 12.5 mg p.o. once daily. allergies: no known drug allergies. however, the patient has had an adverse reaction to ativan. family history: her father had heart disease. social history: the patient used to smoke about twenty-five years ago. she drinks approximately two drinks per day. physical examination: vital signs revealed heart rate around 95, blood pressure around 105/50, respiratory rate approximately 20 and oxygen saturation approximately 96%. the patient was a tired appearing well nourished female in no apparent distress. the pupils are equal, round, and reactive to light and accommodation. the extraocular movements are intact. sclera are anicteric. the patient had dry mucous membranes. she had no jugular venous distention, no lymphadenopathy and no carotid bruits. the heart was regular rate and rhythm, distant heart sounds, right upper sternal border systolic murmur. the lungs were bilaterally clear to auscultation anteriorly with crackles laterally. the abdomen was soft, obese, positive bowel sounds and tender in the lower quadrants secondary to proximity to the groin region. she had multiple ecchymoses over her abdomen. extremities showed no cyanosis or clubbing but had brawny pitting edema up to the midleg with good dorsalis pedis pulses but tibial pulses were blunted by pitting edema. hospital course: the patient was admitted to the ccu for overnight observation of her bilateral groin hematomas which remained stable until morning. her hematocrit also remained stable. given the above, the patient was transferred to the floor and restarted on heparin drip and coumadin for therapy for her atrial flutter and status post electrophysiologic ablation. the patient's other cardiology tests showed: cardiac catheterization showed moderate aortic stenosis, markedly elevated filling pressures with preserved cardiac output and index and mild one vessel coronary artery disease. resting hemodynamics demonstrated severely elevated right and left sided filling pressures with a wedge of 32. her cardiac output and index were preserved with moderate systemic arterial hypertension and moderate pulmonary arterial hypertension. there was moderate aortic stenosis with a peak gradient of 51 and a mean gradient of 37 with a calculated valve area of 0.9 centimeter squared. selective coronary angiography of the right dominant circulation demonstrated mild one vessel disease. the left main coronary artery, left circumflex and right coronary artery were angiographically normal. the left anterior descending had a mild proximal stenosis of 30%. the patient remained in atrial flutter throughout the case. the patient had moderate arterial hematoma after her arterial sheath was pulled and hemostasis was achieved by manual compression with the use of a clamp. the patient had also had an echocardiogram performed the same day which showed right atrium was normal in size, no atrial septal defect was visible, left systolic function appeared depressed, right ventricular chamber size and free wall motion were normal, focal calcifications in the aortic root with simple atheroma in the descending thoracic aorta. there were three aortic valve leaflets. the aortic valve leaflets were severely thickened and deformed and there was 1+ aortic regurgitation. the mitral valve leaflets were mildly thickened with mild thickening of the mitral valve chordae. there was 1+ mitral regurgitation. tricuspid valve leaflets were normal as were the pulmonic valve leaflets. there was a small pericardial effusion. no spontaneous echocardiographic contrast or thrombus was seen in the body of the left atrium, atrial appendage, body of right atrium/right atrial appendage. no atrial septal defect was seen. given the above, the patient was expected to be discharged on coumadin, however, her groin hematomas continued to expand and she was subsequently sent for a ct scan of the abdomen and pelvis to rule out retroperitoneal hemorrhage. these showed a large right groin hematoma extending into the anterior abdominal wall without retroperitoneal extension. there was no way to assess for arterial extravasation given the lack of intravenous contrast. the patient also had small bilateral pleural effusions and cholelithiasis. the patient also had an ultrasound performed of the right femoral artery which showed that there was a large heterogeneous mass in the right groin compatible with hematoma. there was no pseudoaneurysm identified throughout the examination and the examination was somewhat limited by the presence of a large hematoma. there was normal venous flow on the veins distally suggesting that there was no av fistula present. given the above, the patient was thought to be stable and was put in for a repeat hematocrit. this repeat hematocrit showed a significant drop and the patient was reexamined and found to have a drop in blood pressure and also a drop in urine output. therefore, she was transferred from the floor back to the ccu, was aggressively rehydrated with fluids p.o. and intravenously, packed red blood cells. the patient received four units of packed red blood cells before being sent with vascular surgery to the operating room for surgical exploration of her right groin hematoma. the patient returned and was found to have increased drainage through her [**location (un) 1661**]-[**location (un) 1662**] drains, status post procedure. therefore, vascular surgery was called to reevaluate the right groin hematoma. an addendum is to be added to this dictation. [**first name11 (name pattern1) **] [**last name (namepattern4) 15176**], m.d. [**md number(1) 15177**] dictated by:[**name8 (md) 10249**] medquist36 d: [**2185-11-16**] 17:06 t: [**2185-11-16**] 17:58 job#: [**job number 47327**]",1
66,"admission date: [**2161-3-6**] discharge date: [**2161-3-19**] date of birth: [**2094-3-14**] sex: m service: medicine chief complaint: pulmonary embolism found incidentally on a routine staging ct. history of present illness: the patient is a 66 year old male who was most recently discharged from the hospital on [**2161-3-4**]. he had been in his usual state of good health until approximately mid-[**month (only) 958**] when he began to notice dark colored urine, [**doctor last name 352**] colored stools and jaundice. subsequent workup including abdominal cat, liver biopsy as well as multiple ercps as well as multiple interventional radiology interventions, concluded the diagnosis of adenocarcinoma at the head of the pancreas with liver metastasis as well as biliary obstruction. during the past hospital admission patient underwent interventional radiology stenting for a biliary drain and had a routine staging chest ct prior to discharge. review of the ct revealed a pulmonary embolism in a proximal branch of the right pulmonary artery extending to the right lower lobe. the radiologist communicated this to the discharge attending and patient was called back to [**hospital1 18**]. in the emergency department patient had a ct of the head done which showed no intra or extra-axial hemorrhage, mass shift, shift of midline structures or enhancing masses seen. there was no obvious intracranial hemorrhage or obvious metastasis. patient was then started on a heparin drip for anticoagulation for the pulmonary embolism and admitted to the medicine service. review of systems: the patient reports he has had dyspnea for approximately two weeks which has not changed since his past admission. he particularly noticed that he is fatigued while climbing stairs. he denies chest pain, cough, fever, hemoptysis. he denies nausea, vomiting. he denies diarrhea, bright red blood per rectum or melena. stools are normal color now. past medical history: benign gastric cancer, status post partial gastrectomy in [**2142**]. status post right inguinal hernia repair and left inguinal hernia repair. denies coronary artery disease, hypertension or diabetes. right achilles tendon heel rupture, status post repair. right knee surgery for a question of cartilage problems, status post surgery. recently diagnosed pancreatic cancer with liver metastasis, status post biliary stent placement and intervention. allergies: no known drug allergies. adverse reactions: codeine causes nausea. social history: the patient smoked one pack per day of cigarettes times 40 years. he quit approximately two weeks prior to admission when diagnosed with cancer. he is a social drinker and drinks a few drinks every week. he is married and lives on [**hospital3 **] with his wife. [**name (ni) **] previously worked in auto repair, but is now retired. family history: brother died of pancreatic cancer 1.5 years ago. physical examination: vital signs on admission were temperature 99, heart rate 107, blood pressure 149/74, respiratory rate 28, o2 saturation 97% in room air. heent normocephalic, atraumatic. scleral icterus. extraocular motions intact. pupils equally round and reactive to light. neck was supple, there was no lymphadenopathy. pulmonary diminished breath sounds bilaterally and poor air movement, but with good inspiratory effort. had bibasilar crackles. cardiac s1, s2, normal, regular rate and rhythm, no murmurs, gallops or rubs, no elevated jvd. abdomen normoactive bowel sounds, soft, nontender, had a biliary drain intact, nontender. there was no erythema, rebound, guarding. there was trace guaiac positive biliary fluid. there was tenderness in the right upper quadrant and left upper quadrant. on gu exam trace guaiac positive, but patient had positive hemorrhoids. extremities no lower extremity edema. dorsalis pedis 2+ pulses bilaterally. neuro aao times four. cranial nerves ii-xii intact. no focal weakness. good muscle tone and strength. laboratory data: sodium 138, potassium 4.1, chloride 102, bicarb 23, bun 23, creatinine 0.8, glucose 150. white blood count 18.9, hematocrit 30.1, platelets 431. inr 1.2, ptt 23.9. cea 547, ca19-9 226,937. ct of the chest inferior posterior margin of pericardium with a 7 to 8 mm nodular density. small hiatal hernia. atelectasis. a 4 mm subpleural nodular density along the lateral aspect of the left lower lobe. there was no effusion. there was a filling defect of the proximal branch of the right pulmonary artery extending to the right middle lobe and right lower lobe. the appearance of this was consistent with pulmonary emboli. the impression of the ct was that intraluminal filling defects within the pulmonary artery branches to both the right middle lobe and right lower lobe were consistent with pulmonary emboli. ct of the abdomen multiple low attenuation lesions of the liver, low attenuation of the head of the pancreas. ct of the head no intracranial or extracranial hemorrhage, no metastasis. ekg sinus rhythm, rate 90 beats per minute, normal axis, no st-t wave changes. assessment: this is a 66 year old white male with a history of recently diagnosed pancreatic cancer who was called back to [**hospital1 18**] for pulmonary embolism which was found incidentally on a routine staging ct. as there is no contraindication for anticoagulation (negative head ct, guaiac negative stools), patient was started on a heparin drip for anticoagulation. patient subsequently had a prolonged hospital course and the hospital course will be dictated by date. hospital course: on [**2161-3-6**] patient had a head ct, no metastasis to the head, no intracranial or extracranial hemorrhage. patient was started on a heparin drip for anticoagulation and was then subsequently changed to lovenox. patient as well as his wife received teaching on lovenox administration. oncology consult (dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **]/dr. [**last name (stitle) **]. driver) came and evaluated patient again and felt that the best anticoagulation therapy would be lovenox. they felt that once his bilirubin normalized, treatment options would include weekly intravenous therapy with gemcitabine or oral therapy with capecitabine. due to his high bilirubin and the potential interactions of coumadin with capecitabine, the oncology consult recommended dosing of enoxaparin (lovenox) instead of coumadin as anticoagulation. patient wished to receive treatment on [**location (un) **] and doctors [**name5 (ptitle) **]/driver referred him to a local oncologist in [**hospital1 1562**]. additionally, interventional radiology saw the patient and took him to the ir suite for evaluation of his stent. this evaluation revealed a patent common bile duct, however, a new diagnosis of stenosis proximal to the common bile duct stent was seen. ir felt that patient needed additional biliary stenting at a later point in time. on [**2161-3-7**] biliary drainage turned bloody with some clots in the drainage bag. there was a question of whether this was secondary to tumor bleeding, possible liver bleeding with anticoagulation or possible tube track-communication to the portal branch of one of the vessels. approximately 20 cc of bloody clot was found in the bag, but patient was hemodynamically stable. interventional radiology was notified and evaluated patient. on [**2161-3-8**] the patient began to have abdominal pain, particularly lower back pain. there were small amounts of bloody drainage in his biliary bag. patient began to complain of nausea and positive vomiting. abdomen was soft, nontender with no rebound initially. it appeared that there was no output from the stent and that the biliary drainage catheter was obstructed. secondary to the concern for retroperitoneal bleed/tumor bleeding/any further bleeding, ct of the abdomen was done stat to evaluate patient's abdomen. the results of the ct abdomen showed again liver with numerous hypodense lesions consistent with metastasis, but there were no signs of intrahepatic ductal dilatation, no evidence of hemorrhage of the liver lesions and no evidence of bleeding into the abdomen/retroperitoneal area. in addition, patient's white blood count increased from 19 to 28 and there was question of whether this was a stress response versus infection. since patient was afebrile, hemodynamically stable and there began to be minimal output from his biliary drain, it was decided that patient would be closely watched overnight and if there were any problems, patient would be started on empiric antibiotic therapy. in addition, lovenox was discontinued on [**2161-3-8**] in the a.m. after patient had episodes of bloody clots in his bag. over the night the patient had one to two teaspoons of coffee ground emesis and his biliary bag became completely occluded. there was no drainage in the bag whatsoever. in the early morning of [**2161-3-9**] (2:00 to 4:00 a.m.) the patient became febrile to 101.7, blood pressure 90/40, heart rate in the 140s, respiratory rate 26, o2 saturation 96% in room air. there was extreme concern for infection given that his biliary stent appeared to be occluded. blood cultures times two were drawn, patient began to be aggressively hydrated with fluids and patient was started on empiric ampicillin/levofloxacin/flagyl for triple antibiotic coverage. patient's respiratory rate began to increase greatly to the upper 30s and an abg was drawn. this revealed ph of 7.48, pco2 26, po2 39. lactic acid level was 5.7. ekg was done which showed sinus tachycardia, no st-t wave changes. at this point in time it was felt that patient likely had ascending cholangitis secondary to undrained biliary fluid which was leading to sepsis and acidemia. interventional radiology was immediately notified and plans were made to take patient to the interventional suite. patient was hydrated very aggressively with 3 to 4 liters of normal saline and still had decreased urine output. his jvd was flat. in the interventional radiology suite patient's biliary catheter was upsized. at this point in time there was no evidence of a blood clot. ir found his abdomen to be soft, nondistended, nontender. they found that his biliary catheter was patent and the bile was brown after upsizing the drain. secondary to the patient's hypertension/tachycardia/sepsis/ascending cholangitis, patient was taken straight from the interventional radiology suite to the medical intensive care unit. in the micu a left subclavian central axis line as well as an arterial line were placed. he was hydrated aggressively with iv fluids (normal saline) as he appeared to be intravascularly depleted with low blood pressure, tachycardia and decreased urine output. patient did not require the use of any pressors in the micu. patient's cvp, urine output were followed and the goal cvp was between 12 and 14. on admission to the micu his cvp was between 7 and 8. his antibiotics were continued (ampicillin/levofloxacin/flagyl). in addition, lactate, bicarb, hematocrit, urine output were followed closely. the impression at this time was that patient had blood causing a blood clot which subsequently obstructed his biliary drainage, caused biliary fluid to back up causing ascending cholangitis and subsequent sepsis. after interventional radiology had intervened and upsized his biliary drainage tube, there were no more blood clots and the biliary catheter was patent with the bile being brown. the main question at this point in time was what caused the biliary bleeding. there was a question of whether it was tumor bleeding, some sort of tract between one of the portal vessels and the biliary tract, whether there was bleeding of the liver itself with anticoagulation. on the initial cholangiogram that was done there was a question of whether there was a biliary tract fistula with one of the pleural vessels. however, on cholangiogram done on [**2161-3-9**] any apparent fistulous tracts were not identified. this was discussed with the interventional radiology team and they felt that it was safe to anticoagulate patient for his pulmonary embolism. therefore, in the micu patient's anticoagulation was restarted with a heparin drip. on [**2161-3-10**] biliary drainage remained patent. bile was clear and green. white blood count began to decrease. in the medical intensive care unit it had risen to 38% and then to 43%. subsequently it began to decrease down to the lower 30s and then to the mid-20s. in addition, on [**2161-3-10**] alkaline phosphatase/total bilirubin/alt/ast began decreasing as well. blood cultures at this time showed initially a question of gram positive rods. on [**2161-3-10**] patient was stable to be transferred to the floor. on [**2161-3-11**] the patient's biliary catheter drainage tube became clogged again. biliary catheter appeared to be obstructed by a blood clot. interventional radiology came and examined the bag and it was flushed, but it still did not drain. patient's heparin was discontinued and patient was taken to interventional radiology for a tube check (cholangiogram) to check for effective drainage. on [**2161-3-11**] interventional radiology changed the biliary catheter and additionally identified a fistulous tract. a branch of the right hepatic artery was embolized. additionally, blood cultures that were drawn on [**2161-3-9**] returned as enterococcus with sensitivities and identifications still pending. on [**2161-3-12**] enterococcus was identified as enterococcus faecalis with sensitivities pending. patient's hematocrit was checked b.i.d. and remained relatively stable. there was a question of whether patient may need to have a repeat embolization if he continued to bleed or if there was another fistulous tract not identified. patient's coags were checked and inr was between 1.8 to 2.0, so he was not started on heparin and not started on lovenox. there was hesitancy to anticoagulate this patient to run the risk of causing rebleeding, reocclusion and reinfection. on [**2161-3-13**] the biliary stent was patent. bilirubin continued to decrease. lfts continued to decrease. levofloxacin was discontinued as the sensitivities from the cultures were back. it was enterococcus faecalis sensitive to ampicillin and resistant to levofloxacin as well as some synergy with streptomycin. adding streptomycin in addition to ampicillin as well as flagyl was considered, however, it was decided against secondary to the severe potential toxicity related to streptomycin. since the enterococcus was sensitive to ampicillin, this was the primary antibiotic. on [**2161-3-14**] the patient's hematocrit was checked b.i.d. vital signs were stable. inr was 1.8. no changes. on [**2161-3-15**] b.i.d. hematocrit was checked. vital signs were stable. inr was 1.4. on [**3-16**] through [**3-17**] patient's biliary drainage was capped by interventional radiology. a lovenox trial was initiated, in treatment of his pulmonary embolism. the lovenox trial was initiated to determine whether he would be able to tolerate anticoagulation. the thought was that if patient rebled on lovenox, patient would require an ivc filter for prevention of future pulmonary emboli. however, if patient did not rebleed on lovenox, it would be safe to consider patient tolerates lovenox and would be able to take this as an outpatient. the patient tolerated lovenox well during the two day trial. hematocrit was checked b.i.d. and there was no evidence of bleeding. in addition, his stools were guaiaced and there was no evidence of melena or bright red blood per rectum. it appeared that patient's prior episodes of bleeding while on heparin/lovenox were due to the fistulous tract between the branch of the right hepatic artery with the biliary tract. subsequent to his embolization on [**2161-3-11**], there had not been any apparent episodes of bleeding in his biliary drainage bag and it appeared that the source of the bleeding had stopped. on [**2161-3-18**] the patient went to interventional radiology to check the patency of his stent. cholangiogram revealed good patency of the stent and no communication between the biliary ducts and any vessels. the external tube/drainage was removed. the intrahepatic tract was embolized. only the internal stent remained. patient tolerated the procedure quite well. on [**2161-3-19**] patient resumed lovenox. a picc line was placed on the right side for iv antibiotics times 10 days. patient is to continue iv antibiotics (ampicillin only) for a 10 day treatment. he was discharged in good condition on [**2161-3-19**] to home with services. hospital course by issue: 1. pulmonary embolism. patient was readmitted to [**hospital1 18**] for pulmonary embolism. he was initially started on a heparin drip and subsequently switched to lovenox. at various points throughout the admission patient was either on heparin or lovenox, but these were sometimes held, as above. coumadin was not recommended as a form of anticoagulation secondary to his high bilirubin and the potential interactions with coumadin and capecitabine, should patient decide to pursue chemotherapy. patient's discharge medication is lovenox 90 mg subcu q.12 hours. [**name (ni) **] wife had lovenox teaching and she administered lovenox to patient with ease. 2. hematology. as above, anticoagulation with lovenox. in addition, patient had anemia secondary to acute blood loss requiring transfusion of packed red blood cells. 3. prophylaxis. the patient was placed on iv famotidine while he was not eating well. 4. gi. biliary obstruction and jaundice, status post percutaneous drain placement/common bile duct stenting. patient had numerous interventional radiology interventions as dictated above. 5. ascending cholangitis/sepsis. the patient was hypotensive (blood pressure 90/50) tachycardiac to 140, respiratory rate in the 30s, lactate 5.6. it appeared that patient had ascending cholangitis leading to sepsis. blood cultures as well as biliary culture revealed enterococcus faecalis sensitive to ampicillin, resistant to levofloxacin. after patient's final intervention with his common bile duct stent on wednesday, [**2161-3-18**], he is to have 10 days of iv antibiotics (ampicillin). 6. pancreatitis. the patient's amylase and lipase were checked serially throughout his admission. they have fluctuated widely, increasing and decreasing. there are several causative factors to his pancreatitis with post procedure pancreatitis being a contribution as well as the fact that patient has a very large tumor/mass at the head of the pancreas. there could also be some fluctuation as well secondary to a question of intermittent/transient obstruction in the ampulla. patient did not have any abdominal pain and denied abdominal tenderness. at this point in time since he is not symptomatic from the pancreatitis, there will be no further intervention (no ercp will be pursued). patient was discharged on a regular diet which he tolerated well. while he was in-house patient was hydrated aggressively with 125 cc of normal saline per hour while his enzymes were elevated. 7. neurology. head ct was without metastasis or hemorrhage. 8. renal. the patient's creatinine was within normal limits. 9. fluids, electrolytes and nutrition. the patient had iv fluids at 125 cc an hour for rehydration purposes while patient had decreased appetite. of note, patient does have occasional nausea and decreased p.o. intake as well as appetite. there was a question of whether this was secondary to iv flagyl. iv flagyl was discontinued on [**2161-3-19**]. hopefully, patient will have an increase in his appetite. it was decided that iv flagyl was not necessary and that the primary antibiotic would be ampicillin to target enterococcus. 10. access. the patient had a right picc line placed for iv antibiotics times 10 days. 11. pain. the patient was given morphine iv/subcu p.r.n. for pain. patient was discharged with a prescription for p.o. morphine. of note, patient does not have severe pain, but does have occasional back pain when he lays in bed too long. 12. oncology. the patient has pancreatic cancer (adenocarcinoma) with liver metastasis. in addition, tumor burden causes biliary obstruction as well. patient will follow up with an oncologist on [**location (un) **]. 13. communication. the patient's micu course as well as his hospital course were communicated to patient's pcp. [**name initial (nameis) **] pcp is [**last name (namepattern4) **]. [**first name4 (namepattern1) **] [**last name (namepattern1) **] ([**telephone/fax (1) 49945**]). discharge instructions: if the patient starts having bloody stools, fever greater than 100.5, fast heart rate greater than 110, chills/sweating or dizziness with standing/walking, please go to the nearest emergency department. condition on discharge: afebrile, hemodynamically stable. hematocrit is stable times four days (29 to 30) with two days on lovenox. no bloody stools. tolerating lovenox well. it appears that the fistula between the branch of the right hepatic artery and the biliary tract was the cause of the bleeding while on anticoagulation. the fistula has since been embolized and there appears to be no more evidence of bleeding. external biliary drain has been pulled and patient only has an internal drain with his common bile duct stent. since his last manipulation/intervention was on [**2161-3-18**], he should have 10 days of iv antibiotics given his past medical history of sepsis with enterococcus. he is discharged to home in good condition. followup: the patient should follow up with his pcp, [**last name (namepattern4) **]. [**first name (stitle) **], within the first week after being discharged back to [**location (un) **]. patient will follow up with oncology on [**location (un) **]. this was conveyed to dr. [**first name (stitle) **], who will arrange for this. procedures: 1. status post multiple interventional radiology interventions on the common bile duct stenting/biliary system. 2. left subclavian central access line. 3. arterial line. discharge diagnoses: 1. pulmonary embolism. 2. pancreatic cancer with liver metastasis. 3. anemia secondary to blood loss requiring transfusion of packed red blood cells. 4. biliary tract fistula to branch of the right hepatic artery causing acute blood loss, embolized. 5. sepsis likely secondary to ascending cholangitis. had a blood clot in the stent leading to accumulation (no drainage) of biliary fluid. recent micu admission for sepsis. patient did not require use of pressors. 6. pancreatitis, laboratory. patient had no abdominal pain. 7. status post multiple interventional radiology interventions on the biliary system. 8. status post picc placement for iv antibiotics. discharge medications: 1. lovenox 90 mg subcu q.12 hours (dose is 1 mg per kg, patient weighs approximately 95 kg). 2. ambien 5 to 10 mg p.o. q.h.s. p.r.n. for insomnia. 3. ativan 0.5 to 1.0 mg p.o. q.six hours as needed for agitation. 4. ampicillin 2 gm iv q.four hours times 10 days. 5. morphine sulfate 10 mg p.o. q.12 hours as needed for pain. 6. colace 100 mg p.o. b.i.d. p.r.n. 7. senna two tabs p.o. b.i.d. p.r.n. 8. compazine 10 mg p.o. q.four to six hours p.r.n. nausea. 9. effexor xr 75 mg p.o. q.day. instructions are to take one pill every day (75 mg) for five days, then may increase to two pills every day (150 mg). [**name6 (md) **] [**name8 (md) **], m.d. [**md number(1) 4446**] dictated by:[**last name (namepattern1) 16787**] medquist36 d: [**2161-3-19**] 22:05 t: [**2161-3-20**] 08:40 job#: [**job number 49946**]",0
67,"admission date: [**2161-10-27**] discharge date: [**2161-11-3**] date of birth: [**2119-1-26**] sex: m service: neurology allergies: patient recorded as having no known allergies to drugs attending:[**first name3 (lf) 848**] chief complaint: seizures major surgical or invasive procedure: none history of present illness: mr. [**known lastname **] is a 39-year-old right-handed man with a history of epilepsy which began at the age of [**4-2**]/2. he has been followed by dr. [**first name4 (namepattern1) **] [**last name (namepattern1) 74763**] from [**hospital **] [**hospital 25757**] hospital since [**2152**]. he recently moved back to [**location (un) 86**] for family reasons and was sent here by dr. [**last name (stitle) 74763**]. he had a generalized convulsion at the time, without any associated fever or illness. the eeg then apparently showed an abnormality in the left temporal region. he was treated briefly with phenobarbital. he remained seizure-free until he was 23 years old, when he had his second generalized seizure while he was driving on i-95. this was in [**2143**]. he recalls that he suddenly felt like he could control or focus his eyes, and the eyes were rolling back uncontrollably, with the arms becoming rigid within a second. he then lost consciousness. his father was in the car at the time and noted that he had a 15-minute episode of generalized limb shaking. luckily, this did not result in a car accident and the car eventually coasted to a stop. he was taken to a local hospital and dilantin 300 mg a day was started. about 3 years later in [**2146**], he had another generalized seizure, again while he was driving. he was taking dilantin at the time. he woke up in the car confused, and the police told him that he had witnessed seizure activity. his dilantin was increased to 400 mg at that time. he was well until [**2148**] when he had an episode of status epilepticus, in the setting of stress and sleep deprivation. within 1 hour, he had 2 episodes of 20-minute generalized seizure and another 10-minute episode. he was taken to [**hospital6 50929**]. after that, he noted significant cognitive problems with very poor memory and visuospatial skills. after this episode, he was tried on valproate, which did not work. lamictal was then added to the regimen, and ativan was also given for about 6 months. during this time, he continued to have occasional seizures, during which he would spontaneously lose his train of thought very briefly for a few seconds. he may also lose track of time for up to 5-10 minutes at a time. if he forgot to take his medications, he noted an intense nervous or flighty sensation, which would build for several hours. he denies any olfactory, gustatory, or auditory hallucinations. he denies any epigastric sensations or out of body experiences. in [**2152**], he moved to [**location 8398**]for his phd. he was under the care of [**first name5 (namepattern1) **] [**last name (namepattern1) 74763**] at [**hospital **] [**hospital 25757**] hospital. he was admitted to the inpatient epilepsy monitoring unit for about a week. the eeg showed left-sided slowing with epileptiform discharges. he eventually was weaned off the dilantin as he had been on it for quite a long time, and it was not quite effective for him. keppra was added in [**2153**]. he states that his last seizure was about 3 years ago, both in terms of the generalized seizures, as well as the occasional interruptions in his train of thought. he is currently doing well without any clear side effects. he continues to have memory difficulties, which he believes is a residual of the episode of status epilepticus in [**2148**]. he also has some difficulty with visual spatial abilities, and he may forget how to get into or out of a building. he states that he had formal cognitive testing with a neuropsychologist at [**hospital 25757**] hospital. he takes his medications three times daily and prefers tid to [**hospital1 **] dosing. this way, if he misses a dose, it is not a large amount. he is typically delayed with his medications and misses a dose once a week at most. aside from the medications above, he has not tried any other anticonvulsant. typical triggers for his seizures include stress and medication non-compliance. in terms of his epilepsy risk factors, his paternal aunt has generalized seizures, but he does not know the details. his [**hospital1 802**] had a non-febrile seizure at age 4 years old. he denies any history of cns infections, febrile seizures, or significant head injuries. developmental and birth history: as far as he knows, he was born full term via vaginal delivery, without complications. he met all of his developmental milestones and did well in school. past medical history: 1. hypercholesterolemia. 2. myopia. 3. malaria in [**2140**] when he was travelling to [**country 480**]. 4. kidney infection in [**2151**]. social history: he currently lives with his sister. [**name (ni) **] is single and has no children. he just completed his phd in anthropology at [**university/college **]. he is unemployed and in the process of looking for a job. he does not smoke, drink alcohol, or use drugs. family history: his mother has multiple sclerosis and mitral valve prolapse. his father has rapid heartbeat and stroke. his sister has no neurological problems. his [**name2 (ni) 802**] had a non-febrile seizure at age 4 years old. his paternal aunt has epilepsy as described above. alzheimer disease also seems to run in multiple paternal relatives. physical exam: on examination, his blood pressure is 138/90, heart rate 88 and regular, and his respirations are 12. general exam: he appears well, in no apparent distress. eyes: disc margins sharp bilaterally, no scleral icterus. respiratory: clear to auscultation bilaterally. cvs: normal s1, s2. no murmurs. abdomen: no positive bowel sounds. no tenderness. extremities: no peripheral edema. skin: no obvious hyper or hypopigmented lesions. neurologic exam: mental status: the patient is fully awake, alert, and oriented. he gives a full history without difficulty. his language is intact. his calculation and attention are also intact. he is able to register [**5-6**] and recalls [**4-6**] after 5 minutes and [**5-6**] with hints. cranial nerves: perrla, extraocular movements full without nystagmus, visual fields full, face and sensation intact, face symmetric, tongue midline, and no dysarthria. motor exam: normal bulk and tone throughout. there is a mild postural tremor in both hands, no asterixis. slightly decreased finger taps in the left hand. otherwise, full strength throughout. sensory: intact to all modalities throughout. coordination: finger- nose-finger and rapid alternating movements intact. reflexes: 2+ throughout and downgoing toes. gait: narrow-based gait, able to tandem, toe and heel walk without difficulty. no romberg sign. pertinent results: [**2161-10-27**] 11:44pm type-art peep-5 po2-211* pco2-39 ph-7.45 total co2-28 base xs-3 intubated-intubated [**2161-10-27**] 11:44pm lactate-1.6 [**2161-10-27**] 11:44pm freeca-1.07* [**2161-10-27**] 06:51pm glucose-104* urea n-9 creat-1.0 sodium-141 potassium-3.8 chloride-105 total co2-25 anion gap-15 [**2161-10-27**] 06:51pm calcium-8.2* phosphate-2.4* magnesium-2.1 [**2161-10-27**] 06:51pm phenytoin-14.5 valproate-<3 [**2161-10-27**] 06:51pm hct-41.3 [**2161-10-27**] 03:47pm type-art peep-5 o2-50 po2-83* pco2-38 ph-7.27* total co2-18* base xs--8 intubated-intubated [**2161-10-27**] 02:55pm cerebrospinal fluid (csf) protein-27 glucose-94 [**2161-10-27**] 02:55pm cerebrospinal fluid (csf) wbc-1 rbc-1* polys-0 lymphs-84 monos-16 [**2161-10-27**] 01:30pm urea n-13 creat-1.2 [**2161-10-27**] 01:30pm estgfr-using this [**2161-10-27**] 01:30pm lipase-30 [**2161-10-27**] 01:30pm calcium-8.5 phosphate-2.6* magnesium-2.5 [**2161-10-27**] 01:30pm phenytoin-17.1 [**2161-10-27**] 01:30pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg [**2161-10-27**] 01:30pm urine hours-random [**2161-10-27**] 01:30pm urine hours-random [**2161-10-27**] 01:30pm urine gr hold-hold [**2161-10-27**] 01:30pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg [**2161-10-27**] 01:30pm wbc-12.1* rbc-5.64 hgb-16.2 hct-47.1 mcv-84 mch-28.6 mchc-34.3 rdw-13.4 [**2161-10-27**] 01:30pm pt-12.9 ptt-20.9* inr(pt)-1.1 [**2161-10-27**] 01:30pm plt count-153 [**2161-10-27**] 01:30pm fibrinoge-295 [**2161-10-27**] 01:30pm urine color-straw appear-clear sp [**last name (un) 155**]-1.014 [**2161-10-27**] 01:30pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-5.0 leuk-neg mri impression: 1. two small areas of acute infarct right cerebellum. 2. findings indicative of left mesial temporal sclerosis. 3. no enhancing brain lesions. brief hospital course: seizures: patient was transferred from [**hospital3 **] after a status epilepticus. at that time he were intubated for airway protection and admitted into our neurology icu. patient's episode of convulsive status epilepticus at least for 45 minutes by report. there was no clear trigger to this in that he was compliant with his medications and he was not ill at that time. a spinal tap was unremarkable and did not show any evidence of cns infection. there was no systemic infection as well after a thorough workup. his eeg telemetry showed left greater than right temporal lobe discharges interictally but no electrographic seizures. as patient was also having mood disturbance and that keppra can sometimes cause mood lability and psychiatric side effects, this was weaned off and replaced with trileptal. he did do well with the trileptal transition. for the episodes noted of status, he was loaded with dilantin and maintained on stable maintenance dose of 100 mg t.i.d. the lamictal remained the same. he remained stable for discharge on trileptal 600 mg t.i.d., lamictal 150 mg t.i.d., dilantin 100 mg. the dilantin can be tapered off per dr. [**last name (stitle) **] as an outpatient, and you should follow up with her. patient was also given the instructions that he cannot drive by [**state **] state law. psych: he was subsequently noted to have significant mood swings, suicidal and homicidal deation. he was extremely angry with his previous ph.d. professor who he believes has been dishonest and who has hindered his academic advancement. we had psychiatry evaluate him during the hospital stay. at that time, he was no longer suicidal. he was instructed to follow up with his primary care doctor about [**state 28085**] to an outpatient psychiatrist. stroke: for further investigation, a brain mri was done with and without contrast to evaluate for any new lesions or structural changes that may have precipitated this episode of status. it is quite unusual given that he had been seizure-free for almost six years prior to this. the brain mri showed changes in the temporal region consistent with left mesial temporal sclerosis. in addition, there were two small areas of acute stroke found in the cerebellum that was incidental. he was not symptomatic at that time. given the embolic appearance, he had a stroke workup including telemetry, cardiac echo, which demonstrated a pfo. his lipid profile indicated a slightly elevated cholesterol and ldl levels. he was started on aspirin for stroke prophylaxis and zetia for cholesterol control. he was subsequently discharged on [**2161-11-3**]. patient's (ldl) was found to be elevated, and since he had an adverse reaction to statins in the past, he was started on zetia. has been scheduled follow up with dr. [**last name (stitle) **] a stroke neurologist for further work up and management. medications on admission: 1. keppra 500 mg 3 times daily (since [**2153**]). 2. lamictal 150 mg 3 times daily. 3. ativan 0.5 mg p.r.n. 4. multivitamins. 5. calcium. 6. aspirin 81 mg daily. 7. omega-3, 3000 mg a day. 8. coenzyme q10, 15 mg 3 times a week. 9. inderal 40 mg p.r.n. for tremors. discharge medications: 1. lamotrigine 150 mg tablet sig: one (1) tablet po tid (3 times a day). 2. phenytoin sodium extended 100 mg capsule sig: one (1) capsule po three times a day. disp:*90 capsule(s)* refills:*2* 3. oxcarbazepine 600 mg tablet sig: one (1) tablet po tid (3 times a day): brand name only. disp:*90 tablet(s)* refills:*2* 4. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. lorazepam 0.5 mg tablet sig: one (1) tablet po tid prn as needed for for seizure clustering. 6. aspirin, buffered 325 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 7. propranolol 60 mg tablet sig: one (1) tablet po twice a day as needed for tremors. 8. outpatient lab work in 2 weeks, have lab work drawn for na (sodium), trileptal level, lamictal [**last name (un) **], and dilantin level. please fax these results to dr.[**name (ni) 39312**] office. discharge disposition: home discharge diagnosis: status epilepticus right cerebellar stroke patent foramen ovale hyperlipidemia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were transferred from [**hospital3 **] after a status epilepticus (continuous seizure). at that time you were intubated for airway protection and admitted into our neurology icu. you were monitored on eeg, which showed left more than right temporal slowing and occasional left temporal discharges. your lamictal level was slightly low, and you had taken an antibiotic a few weeks prior to admission which may have lowered your seizure threshold. mri head showed left mesial temporal sclerosis. you were tapered off keppra, and started on dilantin and trileptal. the dilantin can be tapered off per dr. [**last name (stitle) **] as an outpatient, and you should follow up with her. mri head showed two small areas of infarct in your right cerebellum. an echocardiogram of your heart was done, which showed a patent foramen ovale, which means that there is a small hole between the two [**doctor last name 1754**] of your heart, which may have allowed a small clot to pass up into your brain. an ultrasound was done of your legs, which showed no signs of clots there. since there were no clots found on ultrasound you were started on a full dose aspirin 325 mg daily. your cholesterol (ldl) was found to be elevated, and since you have had an adverse reaction to statins in the past, you were started on zetia. you have been scheduled to follow up with dr. [**last name (stitle) **] a stroke neurologist for further work up and management. you will need to have an insurance [**last name (stitle) 28085**] and call the number below to register. you had some suicidal ideation after your seizure, and should follow up with your primary care doctor [**first name (titles) **] [**last name (titles) 28085**] to an outpatient psychiatrist. ***by massachusett's law you are unable to drive within 6 months of having a seizure. you should also avoid activities where having a seizure would place you at significant risk such as bathing or swimming alone.*** followup instructions: for your seizures: [**last name (lf) **], [**first name3 (lf) **] d. office phone: ([**telephone/fax (1) 35413**] thursday, [**11-5**] at 10am post hospitalization follow up and cholesterol: primary care physician [**2161-11-13**] at 2:30 pm name: [**doctor last name **],surendra address: [**location (un) 74764**], [**location (un) **],[**numeric identifier 4770**] phone: [**telephone/fax (1) 74765**] fax: [**telephone/fax (1) 74766**] for your stroke: dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] [**2161-12-7**] 2:30pm please a)get an insurance [**year (4 digits) 28085**] from your pcp b)call [**telephone/fax (1) 2574**] to register provider: [**first name8 (namepattern2) **] [**last name (namepattern1) 640**] [**last name (namepattern4) 3445**], md phone:[**telephone/fax (1) 2574**] date/time:[**2161-12-7**] 2:30 completed by:[**2161-11-10**]",1
68,"admission date: [**2111-11-18**] discharge date: [**2111-11-29**] date of birth: [**2048-2-16**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**first name3 (lf) 3561**] chief complaint: unresponsiveness major surgical or invasive procedure: eeg monitoring history of present illness: 63 y.o. female with history of seizures and cva as well as multiple abdominal surgeries and recent mesenteric ischemia s/p bowel resection who was admitted to the general medicine floor lastnight for confusion, hallucinations, increased falls and worsened abdominal pain. in the ed, she was evaluated by neurology where an lp was done and was normal and a ct head showed posterior reversible leukoencephalopathy vs. multiple old cvas. she was additionally seen by surgery to evaluate abdomen and drains were felt to be in place and working well. . this morning, patient was found unresponsive by nurse with right arm twitching, concerning for a seizure. of note, patient has history of a seizure disorder since [**2108**] and was on dilantin until one month ago when it was stopped because of problems with line clogging. she was then switched to [**year (4 digits) 13401**] 500 mg [**hospital1 **]. she was also recently taken off of klonopin. patient was only responsive to sternal rub this morning and a trigger was called for change in mental status. she was given a total of 6 mg of ativan with improvement of twitching. she was additionally loaded with dilantin after which her blood pressure dropped to sbp of 80s. she received a 500 cc bolus with improvement of her bp. the stroke fellow was notified and requested a stat cta head perfusion study. patient was transferred to the icu for further management. past medical history: pvd l subclavian stenosis s/p bypass htn hyperlipidemia copd s/p appendectomy s/p tonsillectomy seizure d/o - since [**2108**] cva '[**08**] bilateral cea cholecystectomy sbo s/p bowel resection mesenteric ischemia s/p further bowel resection with jejunostomy social history: married female living with husband. unknown occupation status. smokes cigarettes: unknown amount, denies alcohol/illicit drug family history: n/c physical exam: general: cachectic, mute and largely unresponsive, though she does withdraw from sternal rub heent nc/at; perrla, cv: s1,s2 nl, no m/r/g appreciated lungs: ctab anteriorly abd: soft with old surgical scars and g and j tubes, well-appearing ext: no c/c/e neuro: limited due to patient's inability to cooperate, but notable for 2+ bilateral biceps reflexes, but otherwise reflexes could not be elicited; upgoing toes bilaterally; skin: no lesions pertinent results: ct head ([**11-18**]): confluent subcortical white matter hypodensity in the frontal and parieto-occipital lobes bilaterally, most likely representing chronic subcortical infarcts. given the distribution, another differential consideration would include pres, which does not appear concordant with the clinical presentation. . cxr ([**11-18**]): no acute cardiopulmonary process. evidence of old granulomatous disease. . csf: #2 chemistry: protein 57 glucose 61 . #4 wbc 0 rbc 0 poly 0 lymph 70 mono 30 eos . ammonia: 25 . 138 99 29 --------------< 117 4.0 32 0.4 ca: 8.8 mg: 2.1 p: 4.9 alt: 73 ap: 276 tbili: 0.3 alb: 2.9 ast: 47 [**doctor first name **]: 69 lip: 78 . wbc: 8.8 hct: 36 plt: 337 n:70.0 l:24.8 m:4.3 e:0.7 bas:0.1 . pt: 13.3 ptt: 27.0 inr: 1.1 brief hospital course: 63 y.o. female with multiple medical problems, admitted for confusion and ?gait instability treating in micu for ? seizure vs status. . seizure: patient has a history of seizures and had been on dilantin, which was switched to [**doctor first name 13401**] because of problems with a clogged picc, though [**name (ni) 13401**] was subtherapeutic. transferred to micu for episode of status vs seizure. she was dilantin loaded and continued on [**name (ni) **]. dilantin levels monitored closely and doses titrated for goal corrected level 20-25. continuous eeg performed without evidence of seizures. . delirium: likely multifactorial. id w/u revealing for gnr in blood (details below) potentially contributing. lp negative. no evidence of seizures on eeg. likely significant contribution of press syndrome(posterior reversible leukoencephalopathy) causing visual hallucinations from the occipital lobes which was managed as below. intermittently responded to zydis. her pain was treated with dilaudid and then morphine elixir after palliative care consult with question of contribution. she was eventually started on standing ativan with improved agitation. . reversible posterior leukoencephalopathy syndrome: seen on mri. this could account for hallucinations, altered ms, and seizures. pls see neurology notes for details. thought [**1-30**] hypertension, which occurs in setting of pain. we maintained goal sbp 140 given proven improvement in sx with good bp control. were not more aggressive given hx of bowel ischemia. . id: grew 2/2 bottles gnr from hickman cath on presentation to micu. other blood cx negative. repeat ct abd performed which showed no evidence of bowel or intraabdominal abscess. surgery was consulted and did not recommend surgery or change of line. recommended treating through it and she received a 14 day course of ceftriaxone. . hx of bowel ischemia s/p resection: as above. surgery followed pt. repeat imaging showed no abscess for drainage. pain control as below . chronic pain: in the setting of multiple abdominal surgeries. pain medications intially minimized to assess mental status. these were added back and she was relatively well controlled with dilaudid iv prn. fentanyl patch was added back. at the recommendation of palliative care, dilaudid was changed to morphine elixir for ease of transition to home. . psych: on multiple medications for depression/anxiety. - continued venlafaxine. held restoril given somnolence . fen: she was profoundly malnurished. tpn for nutrition. . access: right hickman, left piv . code: dnr/dni . dispo: after long discussion with the patient and her family, patient expressed wishes to go home with hospice. with the help of the palliative care team, she was transitioned to morphine and fentanyl for pain, ativan for agitation, and per neuro pr [**month/day (2) **] for seizures. she will not be going home with any iv medications and the hickman will not be used any longer. goals of care is patient's comfort. she will be receiving home hospice while at home. medications on admission: medications (as an outpatient): dilaudid 2mg iv q4h prn pain desenex 2% topical prn tylenol 650mg po q6h prn pain flexeril 10mg po tid prn spasm percocet 1 tab po q4h prn pain compazine 10mg im q6h prn nausea fentanyl patch 25mcg kcl elixer 40meq po bid calcium carbonate 1250mg po bid ativan 2mg po q4h zofran 4mg iv q4h prn plavix 75mg po daily prevacid 30mg po daily vit b12 1000mcg im qmonth msir 15mg po q4h restoril 15mg qhs effexor 37.5mg po bid [**month/day (2) 13401**] 500 mg [**hospital1 **] . allergies/adverse reactions: nkda discharge disposition: home with service facility: [**company 1519**] discharge diagnosis: primary: 1. delerium 2. press syndome 3. hypertension secondary: 1. mesenteric ischemia 2. epilepsy 3. peripheral vascular disease discharge condition: stable discharge instructions: please take all medications as prescribed followup instructions: please follow up with your primary care provider as needed. continues with hospice care completed by:[**2111-11-29**]",0
69,"admission date: [**2135-7-14**] discharge date: [**2135-8-18**] date of birth: [**2066-11-25**] sex: m service: medicine allergies: vidaza / vancomycin attending:[**first name3 (lf) 3913**] chief complaint: fatigue major surgical or invasive procedure: bone marrow biopsies history of present illness: this is a 68 yo m with a history of mds raeb type 1 with myelofibrosis s/p cycle 1 decitabine ending [**2135-6-9**], copd, chronic decubitus ulcers, and neutrophilic dermatosis who has been admitted for further evaluation of weakness. the patient was recently admitted from [**date range (1) 73067**] with fever. during this admission, he was found to have a pan-s e. coli, vancomycin sensitive enterococcus, and [**first name5 (namepattern1) 564**] [**last name (namepattern1) 563**] blood stream infection. he had a tte which did not show signs of endocarditis and a dilated eye exam which did not show [**female first name (un) 564**] endophthalmitis. he received a two week course of vancomycin and cefepime and a plan was made for thirty days of fluconazole (first negative blood culture for yeast [**2135-6-19**]). there was also concern for a multifocal pneumonia in the rul on chest imaging during the [**date range (1) 73067**] admit. the patient underwent bal on [**2135-7-1**], with negative cultures. lastly, he was found to have a transaminitis and hyperbilirubinemia of unclear etiology during his last admission (alt 226, ast 235, t bili 11.3). these lab abnormalities resolved without gi intervention. the patient was discharged on [**7-5**] to home, which is his daughter's home in [**location (un) 3844**]. the patient reports initially feeling well, but then over the last five days, started to experience decrease appetite and fatigue. initially, he thought the decrease in appetite was secondary to a change in taste caused by fluconazole; thus, he stopped taking the fluconazole for a few days. he felt better, but then noticed return of the symptoms. the fatigue increased to the point that he started using a walker at home and even started to notice difficulty getting up from the bed. he denies any fevers, chills, vomiting, new rash, blurry vision, shortness of breath, chest pain, or headache. he has chronic nausea and diarrhea, which have continued. he has also noticed a new pain below his right rib cage which is worse with inspiration. past medical history: 1. myelodysplastic syndrome [dx [**2130**], until [**8-/2134**] treated with only procrit and rbc transfusion, then in [**8-27**] started on azacitidine (vidaza)] w/ adverse reaction, now treated with decitabine. evidence of transformation to aml. 2. s/p right hemicolectomy with end ileostomy/mucous fistula for ischemic bowel perforation ([**2134-9-28**]) 3. s/p back surgeries (multiple) 4. paroxysmal atrial fibrillation (dx [**9-/2134**]) 5. copd 6. carpal tunnel syndrome 7. left knee surgery 8. history of vre positive peritoneal fluid in [**2133**] social history: - retired, used to work for chemical company in office setting - lives with daughter in [**name (ni) 3597**] nh - significant etoh use, stopped seven years ago - 60 pack year history of tobacco use family history: - sister - died scleroderma - brother - died etoh abuse - daughter - marfan's with cardiac problems - mother - died lung ca - father - died [**name2 (ni) 8751**] physical exam: vs: t 96.4, bp laying 109/47 hr 69, bp sitting 111/43 hr 75, bp standing 108/45 hr 79, rr 20, o2 98% ra gen: aox3, nad heent: perrla. dry mucous membranes. no lad. neck supple. no cervical or supraclavicular lad cards: rrr with 2-3/6 sytolic murmur. no gallops/rubs. pulm: ctab no crackles or wheezes abd: bs+, soft, minimal ruq tenderness to palpation under the last rib, no rebound/guarding. patient has dressing covering abdominal wound, which is < 2cm. no erythema. he has a colostomy bag in the r abdomen with liquid stool. extremities: wwp, trace lle edema. dps 2+. skin: + bruising, no visible rash neuro: cns ii-xii intact. patient has intact sensation throughout. pertinent results: admission labs: [**2135-7-14**] 02:30pm blood wbc-2.0* rbc-2.94* hgb-8.9* hct-24.7* mcv-84 mch-30.4 mchc-36.1* rdw-14.2 plt ct-27* [**2135-7-14**] 02:30pm blood neuts-40* bands-6* lymphs-30 monos-2 eos-10* baso-0 atyps-2* metas-2* myelos-0 blasts-8* [**2135-7-15**] 07:10am blood pt-15.2* ptt-29.1 inr(pt)-1.3* [**2135-7-14**] 02:30pm blood urean-44* creat-1.1 na-139 k-5.0 cl-105 hco3-26 angap-13 [**2135-7-14**] 02:30pm blood calcium-10.2 phos-4.8* mg-2.0 [**2135-7-14**] 02:30pm blood alt-44* ast-36 ld(ldh)-196 alkphos-89 totbili-0.9 . [**2135-8-18**] 12:16am blood wbc-2.6* rbc-2.73* hgb-8.3* hct-23.3* mcv-85 mch-30.3 mchc-35.5* rdw-13.8 plt ct-17* [**2135-8-18**] 12:16am blood neuts-25* bands-6* lymphs-32 monos-8 eos-1 baso-0 atyps-0 metas-10* myelos-1* promyel-2* blasts-15* [**2135-8-18**] 02:20pm blood plt ct-31*# [**2135-8-18**] 12:16am blood fibrino-325 [**2135-8-18**] 12:16am blood gran ct-1144* [**2135-8-18**] 12:16am blood glucose-82 urean-23* creat-0.9 na-135 k-3.9 cl-94* hco3-37* angap-8 [**2135-8-10**] 06:15pm blood ctropnt-0.32* [**2135-8-10**] 05:50am blood ck-mb-2 ctropnt-0.36* [**2135-7-21**] 06:52am blood lipase-20 [**2135-8-18**] 12:16am blood calcium-8.7 phos-3.0 mg-1.9 [**2135-7-30**] 07:02am blood caltibc-88* ferritn-6126* trf-68* [**2135-7-15**] 07:10am blood tsh-1.7 [**2135-7-16**] 07:26am blood cortsol-19.2 [**2135-8-11**] 06:58am blood type-[**last name (un) **] po2-153* pco2-59* ph-7.43 caltco2-40* base xs-12 [**2135-8-10**] 06:46pm blood type-[**last name (un) **] po2-121* pco2-62* ph-7.41 caltco2-41* base xs-12 comment-green top [**2135-8-10**] 06:08am blood type-[**last name (un) **] po2-168* pco2-64* ph-7.39 caltco2-40* base xs-11 [**2135-8-3**] 11:34pm blood type-art temp-39.4 po2-68* pco2-54* ph-7.30* caltco2-28 base xs-0 [**2135-8-11**] 06:58am blood glucose-91 lactate-0.9 cl-92* urine culture (final [**2135-7-26**]): enterococcus sp.. 10,000-100,000 organisms/ml.. urine culture (final [**2135-7-19**]): klebsiella pneumoniae. 10,000-100,000 organisms/ml.. piperacillin/tazobactam sensitivity testing available on request. staph aureus coag +. 10,000-100,000 organisms/ml.. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. brief hospital course: 68yo man with mds/aml admitted for weakness/fatigue, diarrhea (high ostomy output), and dehydration. he completed cycle #1 decitabine [**2135-6-9**]. this was complicated by recently admitted from [**date range (1) 73067**] with fever. during this admission, he was found to have a pan-s e. coli, vancomycin sensitive enterococcus, and [**first name5 (namepattern1) 564**] [**last name (namepattern1) 563**] blood stream infection requiring hospitalization [**2135-6-12**] and treatment with cefepime/vancomycin x2wks, and fluconazole x30 days (1st negative blood culture for yeast [**2135-6-19**]). tte and ophthalmic exam for [**female first name (un) 564**] endophthalmitis were both negative. also, imaging showed rul infiltrate. bal [**2135-7-1**] had negative cultures. transaminitis and hyperbilirubinemia of unclear etiology (alt 226, ast 235, t bili 11.3) resolved without gi intervention. he was admitted with fatigue. . # weakness/fatigue: possibly due to dehydration vs. progressive disease vs. infection (recurrence of recent multi-organism sepsis) vs. post-chemo effect (unlikely with decitabine). he received iv fluids. tsh and cortisol were normal. blood and urine cultures were sent: urine culture grew and iv fluids given. blood, fugnal, and urine cultures sent. he was treated with empiric antibiotics and his weakness appeared to improve. the patient was able to ambulate around the [**hospital1 **] with pt and walker assistance, but deteriorated once again, requiring icu admission (see below). however, his weakness waxed and waned thoughout the hospital course, and did not completely resolve by the time of discharge. . # abdominal pain and diarrhea: the patient presented with high ostomy output. he was started on iv hydration and a low residue diet. c. diff toxin and stool culture were sent and were negative. he also complained of ruq pain, with positive [**doctor last name 515**] sign. however uss and hida scan only showed gall bladder sludge and gi and surgery were reluctant to place a percutaneous biliary drain or perform ercp given the high risk of sepsis int his frail neutropenic patient. in addition to the focal ruq pain, the patient also complained of diffuse, migratory abdominal pain. he was treated with empiric antibiotics to treat for gram negative, positive and fungal infections, and his symptoms improved. ct abdomen also revealed epiploic appendagitis, which may have been the cause of his diffuse abdominal pain. . # urinary tract infections: urine cultures from [**2135-7-16**] grew mrsa and klebsiella pneumoniae; urine cultures from [**2135-7-23**] grew enterococcus, and the patient presented with abdominal pain and hypotension. on both occasions, appropriate antibiotics were started, and the patient's urinary symptoms and culture positivity resolved. . respiratory distress: on admission, the patient had cxr and ct findings of a diffuse infiltrative process. over the course of his hospitalization, the patient had variable degrees of respiratory distres; sometimes requiring increasing amounts of oxygen for satisfactory blood oxygen saturation. he frequently developed pulmonary edema, which was however responsive to lasix. he underwent a thoracentesis to drain pulmonary effusion on [**2135-8-3**]. however, he became tachypneic and desaturated and was transferred to the icu for flash pulmonary edema. in the icu, his oxygen saturation improved on high flow oxygen. he was treated with nebulizers and oxygen and transferred back to the floor shortly thereafter. on the floor he developed some pleuritic chest pain, but this resolved with oxycodone and cardiac enzymes were negative. ct chest prior to discharge showed that his chest infiltrates were improving. . # mds: s/p decitabine finished cycle #1 [**2135-6-9**]. on readmission, his peripheral blood morphology was concernign for mds, but bone marrow biopsy on [**2135-7-17**] showed only 8% blasts. nevertheless, over the course of this hospitalization, the patient continued to have non-specific weakness, and remained pancytopenic. bone marrow biopsy was repeated on [**2135-8-11**] and showed a hypercellular marrow consistent with raeb-2. mr. [**known lastname **] will requrie close outpatient followup and readmission for cycle 2 of decitabine chemotherapy. . # anemia and thrombocytopenia: likely secondary to mds and chemotherapy. the patient required frequent blood and platelet trasnfusions during his hospitalization. medications on admission: 1. furosemide 40 mg-tablet sig: one (1) tablet po daily (daily). 2. lorazepam 0.5 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia. 3. morphine 30 mg tablet extended release sig: one (1) tablet extended release po at bedtime. 4. oxycodone 5 mg tablet sig: two (2) tablet po 8:00am, 12:00pm, 4:00pm, and 8:00pm as needed. 5. oxycodone 5 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 6. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 7. zinc sulfate 220 mg capsule sig: one (1) capsule po daily (daily). 8. multivitamin tablet sig: one (1) cap po daily (daily). 9. ascorbic acid 500 mg tablet sig: one (1) tablet po daily (daily). 10. prochlorperazine maleate 5 mg tablet sig: 1-2 tablets po every eight (8) hours as needed for nausea. 11. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation: this can be purchased over the counter. 12. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation: this can be purchased over the counter. discharge medications: 1. acyclovir 400 mg tablet sig: one (1) tablet po q8h (every 8 hours). disp:*60 tablet(s)* refills:*2* 2. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). disp:*60 tablet(s)* refills:*2* 3. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours). disp:*90 tablet(s)* refills:*2* 4. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours). disp:*60 tablet(s)* refills:*2* 5. morphine 30 mg tablet extended release sig: one (1) tablet extended release po q8h (every 8 hours). disp:*90 tablet extended release(s)* refills:*2* 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 8. multivitamin tablet sig: one (1) tablet po daily (daily). 9. ascorbic acid 500 mg tablet sig: one (1) tablet po daily (daily). 10. prochlorperazine maleate 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for nausea. 11. oxygen o2 at 2l continously with pulse dose system for portability. dx copd/pna 12. oxycodone 5 mg tablet sig: one (1) tablet po four times a day as needed for pain. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: [**location (un) 4480**] rehab home care discharge diagnosis: 1. pneumonia 2. myelodysplastic syndrome 3. anemia 4. thrombocytopenia 5. urinary tract infection 6. copd discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: mr. [**known lastname **], you were admitted to [**hospital1 1170**] because of weakness and fatigue with high ostomy output. we found that you had a pneumonia and you were treated. we found that you had an infection of you gastrointestional track, which has been treated. we found you had a urinary tract infection, which has been treated. you also had a bone marrow biopsy that reveal that you continue to have a myelodysplastic syndrome. medication changes: stop taking furosemide stop taking lorazepam stop taking omeprazole change to ms contin 30mg by mouth every 8 hours start taking oxycodone 5mg by mouth every 6 hours as needed for pain start taking ciprofloxacin 500mg by mouth every 12 hours start taking metronidazole 500mg by mouth every 8 hours continue taking the acyclovir 400 by mouth three times daily continue taking ascorbic acid 500mg by mouth daily continue taking docusate 100mg by mouth two times daily continue taking fluconazole 200mg 2 tablets daily continue taking a multivitamin daily continue taking prochlorperzaine maleate 5mg 1-2 tablets by mouth every six hours as needed for nausea continue taking senna 1 table twice a day as needed for constipation stop taking zinc slfate 220mg daily followup instructions: please follow up on sunday, [**2135-8-21**] for lab work. department: hematology/[**year (4 digits) 3242**] when: thursday [**2135-8-25**] at 10:00 am with: [**first name11 (name pattern1) **] [**last name (namepattern4) 7779**], md [**telephone/fax (1) 3241**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) **] campus: east best parking: [**hospital ward name 23**] garage department: hematology/[**hospital ward name 3242**] when: thursday [**2135-8-25**] at 10:00 am with: [**first name11 (name pattern1) **] [**last name (namepattern4) 9574**], np [**telephone/fax (1) 3241**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) **] campus: east best parking: [**hospital ward name 23**] garage department: hematology/[**hospital ward name 3242**] when: thursday [**2135-8-25**] at 10:30 am with: [**first name4 (namepattern1) **] [**last name (namepattern1) 3920**], rn [**telephone/fax (1) 3241**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) **] campus: east best parking: [**hospital ward name 23**] garage completed by:[**2135-8-29**]",1
70,"admission date: [**2118-9-29**] discharge date: [**2118-10-6**] date of birth: [**2055-1-4**] sex: f service: medicine allergies: sulfa (sulfonamides) attending:[**first name3 (lf) 6180**] chief complaint: fever and hypotension major surgical or invasive procedure: 1. none history of present illness: oncology history: patient was originally diagnosed with breast cancer in [**2113**]. at time of diagnosis she had a t1n0m0, er+, pr-, her-2/neu- lesion treated with lumpectomy and xrt. the patient had received tamoxifen since [**2113-12-25**] without additional adjuvant chemotherapy and without known progression of disease to date as per patient's report. the patient's tamoxifen was discontinued upon diagnosis of second primary malignancy. in late [**2117-11-24**], the patient presented with abdominal pain. a ct at that time revealed a mass in the pancreas w/extension to the left adrenal and kidney with biopsy revealing mucinous adenocarcinoma. the patient is now s/p distal pancreatectomy, splenectomy, l adrenalectomy, l nephrectomy, and omentectomy for this lesion. she began treatment with xrt/xeloda and was then discovered to have metastatic disease for which gemcitabine/cisplatin were initiated. most recently the patient has been receiving irinotecan and xeloda in [**2118-8-25**] in the setting of rising ca19-9 which has been followed by good response with a drop in her ca19-9 from 1549 to 439. her last dose of irinotecan was [**9-14**]. the patient was nearing completion of her second cycle of xeloda with her last dose taken on tuesday [**9-27**]. she was to complete her cycle wednesday night but was told to hold further doses given her symptoms for which she presented. her next scheduled cycle was to begin wednesday, [**2118-10-5**], but may be postponed given current symptoms. . the patient was reported to be in her usoh until sunday afternoon when she developed onset of diarrhea. she was visiting friends in [**name (ni) **] at the time and previously reported she felt well. she reports small hiking but denies insect bites, tick bites, rashes, drinking stream or [**doctor last name **] water. the patient continued to have diarrhea and called her oncologist on tuesday for her ongoing symptoms. she was instructed at this time to hold her xeloda. the patient reported additionally decreased p.o. intake over the prior 48h. on the evening of presentation, the patient went to a hotel room to lie down. the patient was found by her partner to be somnolent. she was arousable but reported to be sleepy and unable to verbalize response. the patient was taken to [**hospital1 18**] by taxi, with assistance. on the way to the hospital, she reports one episode of non-bloody, non-bilous vomiting. she denied on admission any ongoing fevers/chills, rashes, headaches, visual changes, chest pain, sob, cough, or abdominal pain. she denied any sick contacts. . in ed her vitals were as follows: 102.1, 105, 79/52, 18, 96% ra. patient was noted to have altered ms, was confused and somnolent. she received cefepime 2g, vancomycin 1g, hydrocortisone 100mg, and levofloxacin 500mg iv x1. the patient's elevated inr was reversed w/ 1 u ffp for possible lp. however, the patient's ms improved w/3l ns with improvement in her blood pressure and an lp was not performed. . interval history: since admission to the micu, the patient was noted to have episode of hypotension with sbp's in the 60's to 70's for which she received 2 500cc ns boluses. patient continued to be hypotensive overnight and was additionally bolused another 500cc ns as well as 500cc lr. patient was noted to have ongoing diarrhea and one episode of non-bilious, non-bloody vomiting overnight as well with dinner. she tolerated breakfast on the am of trasnfer to floor, but reports ongoing fatigue. she additionally reports some f/c this am but denies any additional n/v, abdominal pain. she denies any ha, neck stiffness, photophobia. she reports her mental clarity to be much improved since admission. . allergies: sulfas - patient reports adverse reaction to sulfa containing eye drops previously past medical history: pmhx: - breast ca, t1n0m0, er+, pr-, her-2/neu-, s/p lumpectomy and xrt, on tamoxifen since [**12-25**], which was stopped with initiation of chemotherapy - pancreatic ca, as above - htn - dvt - [**7-29**] - diagnosed asymptomatically by abd ct - migraines social history: patient is currently retired. previously employed as a superintendent for school district in [**state 4565**]. patient denies etoh/tobacco/ivdu. patient with male partner of 25 years, previously married with 2 children from previous marriage. travel history as above to nh recently. previously received her care with [**doctor last name 21721**] in ca, referred to dr. [**first name (stitle) **] for 2nd opinion, the reason for which she is currently in [**location (un) 86**]. family history: mother deceased brain tumor age 54 father deceased [**name2 (ni) 499**] ca age 64 physical exam: physical exam vitals: tc:97.7___ tmx:101 ([**2118-9-28**] 21:00)____ bp:120/59___ hr:94_____ rr:15____ o2 sat: 99% on ra rectal tube: 2835cc over last 24 hours . gen: patient is a middle aged female, appears chronically ill but not greatly malnourished, in nad heent: ncat, eomi, perrl. op: mmm, no lesions neck: no lad, no jvd. supple chest: mildy decreased bs at left base, otherwise cta a+p cor: mildly tachycardic, no m/r/g abd: firm but not rigid, mild/mod tenderness diffusely but greater in llq without rebound or guarding. +nabs with occasional borborygymi extrem: no c/c/e access: left chest port, + foley, + rectal tube pertinent results: admission labs: [**2118-9-29**]: . [**2118-9-29**] 01:25am plt count-271 [**2118-9-29**] 01:25am pt-21.8* ptt-27.6 inr(pt)-3.4 [**2118-9-29**] 01:25am hypochrom-normal anisocyt-1+ poikilocy-2+ macrocyt-2+ microcyt-normal polychrom-normal ovalocyt-occasional target-occasional schistocy-occasional burr-occasional teardrop-occasional how-jol-occasional [**2118-9-29**] 01:25am neuts-33* bands-8* lymphs-28 monos-24* eos-2 basos-0 atyps-1* metas-2* myelos-0 nuc rbcs-2* other-2* [**2118-9-29**] 01:25am wbc-1.7* rbc-3.37* hgb-11.5* hct-33.8* mcv-100* mch-34.0* mchc-33.9 rdw-20.1* [**2118-9-29**] 01:25am albumin-3.8 calcium-8.5 phosphate-1.4* magnesium-1.4* [**2118-9-29**] 01:25am lipase-9 [**2118-9-29**] 01:25am alt(sgpt)-10 ast(sgot)-13 alk phos-68 amylase-15 tot bili-1.7* [**2118-9-29**] 01:25am glucose-155* urea n-19 creat-1.3* sodium-130* potassium-3.4 chloride-98 total co2-20* anion gap-15 [**2118-9-29**] 01:43am lactate-1.8 [**2118-9-29**] 02:20am urine granular-[**6-3**]* hyaline-[**2-26**]* [**2118-9-29**] 02:20am urine rbc-[**2-26**]* wbc-[**2-26**] bacteria-few yeast-none epi-[**2-26**] [**2118-9-29**] 02:20am urine blood-mod nitrite-neg protein-tr glucose-neg ketone-15 bilirubin-sm urobilngn-neg ph-6.5 leuk-neg [**2118-9-29**] 02:20am urine type-random color-amber appear-hazy sp [**last name (un) 155**]-1.026 [**2118-9-29**] 08:14am urine rbc-0 wbc-0 bacteria-none yeast-none epi-<1 [**2118-9-29**] 08:14am urine blood-tr nitrite-neg protein-neg glucose-100 ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg [**2118-9-29**] 08:14am urine color-straw appear-clear sp [**last name (un) 155**]-1.010 [**2118-9-29**] 08:14am pt-24.6* ptt-29.1 inr(pt)-4.4 [**2118-9-29**] 08:14am plt smr-normal plt count-241 [**2118-9-29**] 08:14am hypochrom-1+ anisocyt-2+ poikilocy-2+ macrocyt-3+ microcyt-normal polychrom-normal ovalocyt-occasional schistocy-1+ burr-occasional how-jol-1+ [**2118-9-29**] 08:14am neuts-39* bands-14* lymphs-25 monos-17* eos-0 basos-0 atyps-3* metas-2* myelos-0 nuc rbcs-2* [**2118-9-29**] 08:14am wbc-1.9* rbc-2.90* hgb-9.5* hct-28.8* mcv-100* mch-32.7* mchc-32.8 rdw-19.7* [**2118-9-29**] 08:14am calcium-7.6* phosphate-1.8* magnesium-1.9 [**2118-9-29**] 08:14am glucose-169* urea n-16 creat-0.8 sodium-135 potassium-3.3 chloride-109* total co2-16* anion gap-13 additional pertinent labs/studies: . [**2118-10-4**] abg - po2-92 pco2-22* ph-7.40 calhco3-14* base xs--8 [**2118-9-29**] venous lactate-1.8 [**2118-10-2**] venous lactate-1.2 [**2118-10-4**] venous lactate-1.4 . trends: wbc: 8.9 <- 5.1 <- 4.9 <- 3.2 <- 1.5 <- 2.4 <- 1.9 <- 1.7 anc: 2950 ([**2118-10-4**]) <- 1369 <- 1290 <- 590 ([**2118-10-1**]) hct: 26.2 <- 27.4 <- 29.6 <- 31.0 <- 25.8 <- 26.2 <- 28.8 <- 33.8 inr: 6.3 <- 4.8 <- 4.2 <- 6.0 <- 3.1 <- 4.2 <- 4.4 <- 3.4 . microbiology: [**2118-9-29**] blood cx - no growth [**2118-10-1**] blood cx - no growth [**2118-10-2**] blood cx - no growth [**2118-10-3**] blood cx - no growth . [**2118-9-29**] stool cx - no salmonella, shigella, or campylobacter found. few charcot-[**location (un) **] crystals present. few polymorphonuclear leukocytes. no ova and parasites seen. c. diff negative [**2118-9-30**] stool cx - moderate polymorphonuclear leukocytes. no ova and parasites seen. [**2118-10-1**]: stool: negative for c. diff [**2118-10-2**]: stool: negative for c. diff [**2118-10-4**]: stool cxs - no growth to date [**2118-10-5**]: stool cxs - no groeth to date . [**2118-9-29**]: urine cx - no growth [**2118-10-3**]: urine cx - no growth . radiology: [**2118-9-29**]: chest pa/lat: chest ap: surgical clips are visualized over the right lateral upper chest. the right costophrenic angle has been excluded from the study. a left-sided port-a-cath is visualized with its tip in the proximal svc. the heart size, mediastinal and hilar contours are unremarkable. the lungs are clear. there are no pleural effusions. the pulmonary vasculature is normal. impression: no acute cardiopulmonary process. . [**2118-9-29**]: ct head: findings: there is no intracranial mass effect, hydrocephalus, shift of normally midline structures or major vascular territorial infarction. the density values of the brain parenchyma are within normal limits. surrounding soft tissue and osseous structures are unremarkable. impression: no mass effect or hemorrhage. . [**2118-9-30**]: port-a-cath flow study: 1. flow study through the port was suggestive of either a fibrin sheath, or less likely, a small catheter leak. 2. good flow was obtained on aspiration of the port at the end of the examination. . [**2118-10-4**]: ct abdomen + pelvis: the lung bases are clear. patient has prior distal pancreatectomy, splenectomy and radical left nephrectomy. in the left upper quadrant posteriorly, there is ill-defined area of soft tissue density located just posterior to the surgical clips to the left and slightly inferior to the celiac artery axis origin. this area of tissue density measures up to 2.8 cm ap x 1.6 cm transverse. this could represent postoperative thickening but correlation with any prior imaging is advised to exclude the possibility of local recurrence. the remaining portion of the proximal pancreatic body, neck and head appear normal. no intra or extrahepatic biliary dilatation. the liver is normal in size. multiple sub cm ovoid hypoattenuating areas mainly in the left lobe ,these may represent small cysts but are too small to characterise on ct and should be correlated with prior imaging or interval follow up as small hypovascular metastases cannot be excluded. the gallbladder and right adrenal gland are normal. the remaining right kidney is normal in size, 1.5 cm fluid attenuating cyst in the upper pole cortex. the abdominal aorta is normal in caliber. no intra-abdominal ascites. in the lateral mid abdominal mesentry, there is a 9 mm area of nodularity just anterior to and separate from the descending [**month/day/year 499**] (series 3 image 48) and a 5 mm area of nodularity more superiorly (series 3, image 43). there is no abnormal large or small bowel loop dilatation. many of the small bowel loops are mildly prominent, measuring up to 3 cm in diameter and the [**month/day/year 499**] is fluid filled throughout which may be due to a current episode of enteritis. . pelvis: a small 2 cm fluid attenuating locule in the posterior inferior pelvis. the uterus is normal in size. no pelvic mass lesions or lymphadenopathy. no concerning bone lesions demonstrated on bone window setting. . conclusion: 1)fluid filled non-thickened non-distended [**month/day/year 499**] .this may be related to current episode of enteritis depending on current clinical correlation. 2) no definite evidence of metastatic disease. there are a number of findings which require correlation with prior postoperative imaging if available or otherwise interval follow.these include an ill- defined area of thickening of the posterior operative site in the left upper quadrant, two sub cm areas of nodularity in the left abdominal mesentery and sub cm hypodensities mainly in the left lobe of the liver. discharge labs: . [**2118-10-6**] 07:25am blood wbc-5.8 rbc-2.90* hgb-9.5* hct-28.9* mcv-100* mch-32.6* mchc-32.7 rdw-20.8* plt ct-458* [**2118-10-6**] 07:25am blood neuts-46* bands-6* lymphs-16* monos-23* eos-2 baso-0 atyps-0 metas-5* myelos-2* nrbc-41* [**2118-10-6**] 07:25am blood hypochr-occasional anisocy-2+ poiklo-2+ macrocy-2+ microcy-normal polychr-occasional target-occasional schisto-1+ how-jol-occasional acantho-2+ [**2118-10-6**] 07:25am blood fibrinogen - pending [**2118-10-6**] 07:25am blood glucose-98 urean-3* creat-0.7 na-134 k-3.8 cl-108 hco3-15* angap-15 [**2118-10-6**] 07:25am blood calcium-7.5* phos-2.0* mg-2.0 brief hospital course: patient is a 63 year old female with pancreatic cancer, recently receiving treatment with her 2nd cycle of xeloda and irinotecan who presents to hospital with fever, hypotension, and altered mental status. . #. hypotension/diarrhea - on presentation, the patient's presentation was assessed to meet criteria for sirs with a septic like picture on presentation. the patient was febrile, hypotensive with altered mental status in the setting of an anc of 590. while in the ed, the patient had cultures drawn, and was initially treated with cefepime, vancomycin, levofloxacin, and hydrocortisone. upon transfer to the micu, the patient was maintained on therapy with cefepime and vancomycin for treatment of febrile neutropenia. the patient had received 3l ns hydration initially and was given ffp with intention to reverse the patient's elevated inr (patient on coumadin for dvt) for possible lp. however, after hydration the patient's mental status was noted to significantly improve and an lp was not attempted at this time. the patient had a lactate of 1.8 with good response in blood pressure with hydration. overnight in the icu on the day of admission the patient had two episodes of hypotension, with systolics in the 60's to 70's range necessitating 2ns and 2lr boluses, again with good response. it was the impression of the treating attending oncologist that the patient's presentation and diarrhea was consistent with chemotherapy induced diarrhea rather than an infectious diarrhea. for this reason, the patient was started on anti-motility agents including lomotil and questran. however, these agents had little effect initially as the patient continued to have high volume diarrhea. in the 24 hours after admission, the patient was assessed to have a gi output of about 2800cc. the patient upon transfer to the floor had a rectal tube and foley in place. however, given that the patient had an anc < 1000 at that time, the decision was made that invasive catheters should likely be removed. as the patient has been largely incontinent of stool, it has been difficult objectively to quantify exact gi output. the patient reported that over the course of her hospital stay, she has not felt that there has been great improvement to date in the quantity of stool produced ,although she has reported increased continence. however, the day prior to discharge to receiving hospital, the patient endorses two to three liquid green bowel movements that she reports she was not even aware of until they had passed. the patient has not required fluid bolusing since trasnfer to the floor, but has been receiving constant iv hydration with ns with 20meq kcl requiring electrolyte repletion q12hr. the patient continues to have a significant non-gap acidosis secondary to diarrhea with serum bicarbonate levels of 11 to 14 over the last three days prior to discharge. however, an abg performed on [**2118-10-4**] as follows: po2-92 pco2-22* ph-7.40 calhco3-14* base xs--8 revealed that the patient is not acidemic and adequately compensating for her bicarbonate loss. as the patient has had a normal serum ph she has not been receiving oral or iv bicarbonate but continues to receive hydration and volume repletion with ns at 125 to 175 cc/hr. as the patient continues to have significant gi output, she will require ongoing hydration and additionally should receive electrolyte panels with repletion q12hrs until no longer needed. in an attempt to decrease the patient's gi output, in addition to lomotil and questran which were initiated on admission, the patient has serially been given kaopectate and the day prior to discharge was started on octreotide and metamucil to help bulk her very liquidy green stool. the patient has now been afebrile > 48 hours, and is currently receiving still cefepime 2gm iv q8hr, now day 8 (started [**2118-9-29**]) and flagyl which was initiated in place of vancomycin (now day 4, initiated [**2118-10-3**]). as the patient has been afebrile for > 48 hours consideration may be made towards discontinuing these medications but will be left to the discretion of the receiving hospital. the patient has had multiple stool and blood cultures sent during this admission (see pertinent results) which have demonstrated mild to moderate leukocytes in the stool but cultures, o+p and c. diff have been negative multiple times. as the patient reported some mild llq tenderness a ct of the abdomen was obtained to detect any occult abscess or other infectious process. ct results demonstrated soft tissue density a the site of the patient's known prior pancreatic mass but revealed no abnormal large or small bowel loop dilatation. ct demonstrated many of the small bowel loops to be mildly prominent, measuring up to 3 cm in diameter and revealed the [**month/day/year 499**] to be fluid filled throughout, thought to be related to the patient's ongoing enteritis. in the pelvis ct additionally revealed a small 2 cm fluid attenuating locule in the posterior inferior pelvis. the patient is now being transferred to receiving hospital for ongoing management of patient's diarrhea and electroylte abnormalities. . #. dvt - the patient on admission was being treated with 2.5mg po qhs of coumadin qhs for known dvt diagnosed in 08-[**2117**]. the patient's inr on presentation was 3.4 which was partially reversed with 1u ffp in anticipation of possible lp. however, as above, given reversal of somnolence with volume rescucitation alone, an lp was not performed. the patient's coumadin was held throughout her stay as she continued to have a supratherapeutic inr without coumadin, thought likely to be secondary to her poor po intake as well as extinguishing gut flora with antibiotics. the patient's inr was 6.0 on [**2118-10-2**] for which she received 2.5mg po vitamin k with good effect, and reduction of her inr to 4.2 the next day. the patient in error however was given a dose of 2.5mg coumadin x1 despite a holding order the following day. her inr was again elevated to 6.3 the day prior to discharge. as the patient's inr was greater than 5, but without any evidence of any ongoing bleeding, the patient's coumadin continues to be held and an addiitional 2.5mg po vitamin k was administered. the patient's inr the am of discharge was found to be 7.0. the patient was given 5mg vitamin k sc this am with concern that previous po doses are not being well absorbed given the patients rapid gi transit time. of additional note, the patient has been noted previously and again this am to have occasional schistocytes on peripheral blood smear. a fibrinogen level checked previously was 543 on [**2118-10-3**] and repeat fibrinogen am of discharge, [**2118-10-6**] was 418, not consistent with dic. the patient should continue to have her inr carefully monitored at the receiving hospital with consideration towards additional vitamin k sc/iv for reversal of inr > 5.0 or ffp with any signs of bleeding. . #. access - in the icu on admission, the patient's port was noted to be not functioning properly. a flow study was performed which demonstrated fluid flow proximal to the catheter tip suggestive likely of a fibrin sheath vs. a possible catheter leak. the port was used once on the floor prior to the results of the flow study being revealed and the patient reported some burning at the port entry site with the infusion of some fluids with potassium. therefore, the port has not been used again during this hospital course and the port should not be used any longer. the patient's port likely will have to be removed given it is not functional. plans were to be made to have the port removed now that the patient has been afebrile > 48hours and hemodynamically stable. upon transfer to the receiving hospital, plans will need to continue to be initiated towards port removal or alternatively attempts could be made to have an attempted snare by interventional radiology for removal of a fibrin sheath if present. the patient is aware the port is not functional and aware it will likely need to be removed. . #. pancreatic ca: as discussed in h+p, the patient is currently s/p distal pancreatectomy, left adrenal/nephrectomy, ometectomy treated additionally with xrt and xeloda, follwed by gemcitabine/cisplatin, and most recently treated with xeloda/irinotecan s/p two 3-week cycles. the patient was travelling to [**location (un) 86**] for second opinion regarding treatment options when she developed severe diarrhea and hypotension. given the patient's apparent chemo toxicity, chemo was held currently until patient is medically stable to continue. impression of oncologist seeing patient at [**hospital1 18**] is that of the two agents, the xeloda may be more responsible for the treatment response to date and the irinotecan her current gi toxicity. given this, considerations towards additional chemo included xeloda alone, possibly with the addition of low dose irinotecan if tumor markers began to rise again. alternatively, patient could additioanlly receive folfox or taxotere as well. the patient is being discharged to receiving hospital currently with plans towards continuing management of diarrhea, electrolyte abnormalities as outlined above and will continue treatment planning with regards to her pancreatic ca with her oncologist. . #. htn - given patient's admission for hypotension, her outpatient regimen of propranolol was held during her hospital course. upon resolution of large gi output and decreased need for iv volume sresuscitation, consideration could be made towards reinitiating patient's antihypertesnive regimen. . #. fen- patient was kept on a low fat, lactose free brat diet with supplemental pancrease given. patient's po intake was not optimal during hospital course, but continues to improve with resolution of her symptoms. . #. communication: patient's significant other, [**name (ni) **] may be reached at [**telephone/fax (1) 62493**].; he is very supportive and intimately involved in the patient's care. medications on admission: medications - outpatient: pancrease 1 capsule orally before meals coumadin 5 mg po qd xanax 0.25 mg [**12-26**] tab po qid prn anxiety propranolol 40 mg po bid prochlorperazine 10 mg po qid prn nausea capecitabine (xeloda) 500 mg 4 tabs qam, 3 tabs qpm x 14 days. loperamide 2 mg po prn diarrhea tylenol prn erythropoetin 20,000u sq qwk. . meds on transfer to floor from micu: riss lorazepam 0.5-1 mg iv q4h:prn acetaminophen 325-650 mg po q4-6h:prn pangestyme-ec 2 cap po tid w/meals cefepime 2 gm iv q12h, day 2 cholestyramine 4 gm po bid vancomycin hcl 1000 mg iv q 12h d 2 epoetin alfa 8000 unit sc discharge medications: 1. amylase-lipase-protease 20,000-4,500- 25,000 unit capsule, delayed release(e.c.) sig: two (2) cap po tid w/meals (3 times a day with meals). 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 3. epoetin alfa 4,000 unit/ml solution sig: 8000 (8000) unit injection qmowefr (monday -wednesday-friday). 4. cholestyramine-sucrose 4 g packet sig: one (1) packet po bid (2 times a day). 5. potassium & sodium phosphates [**telephone/fax (3) 4228**] mg packet sig: two (2) packet po bid (2 times a day). 6. metronidazole 500 mg tablet sig: one (1) tablet po q6 (). 7. prochlorperazine 10 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. 8. bismuth subsalicylate 262 mg tablet, chewable sig: one (1) tablet po q3h (every 3 hours) as needed for diarrhea. 9. psyllium packet sig: one (1) packet po tid (3 times a day). 10. lorazepam 2 mg/ml syringe sig: one (1) mg injection q4h (every 4 hours) as needed. 11. cefepime 2 g piggyback sig: two (2) grams intravenous q8h (every 8 hours). 12. octreotide acetate 50 mcg/ml solution sig: fifty (50) mcg injection q8h (every 8 hours). discharge disposition: extended care discharge diagnosis: primary: sirs hypotension chemotherapy related diarrhea pancreatic cancer . secondary: breast cancer hypertension dvt - [**7-/2118**] migraines discharge condition: 1. fair. patient is being transferred to receiving hospital in [**state 4565**] for ongoing management. patient is currently afebrile, normotensive, with ongoing large liquid bowel movements and requiring frequent electrolyte repletion. discharge instructions: 1. please take all medications as prescribed unless instructed otherwise by receiving hospital . 2. please continue outpatient follow up with your oncologist in [**state 4565**] and continue to contact dr. [**first name (stitle) **] at [**hospital1 18**] as desired for ongoing treatment options. . 3. upon discharge from receiving hosptial, please return to hospital for any signs or symptoms of increasing diarrhea, dizziness, fever, intractable nausea/vomiting, bleeding or any other concerning symptoms. followup instructions: 1. please continue treatment under the supervision and care of receiving hospital in [**state 4565**] . 2. please call your oncologist upon discharge for ongoing care and treatment plans",1
71,"admission date: [**2121-6-10**] discharge date: [**2121-6-18**] date of birth: [**2043-7-2**] sex: f service: cme history of present illness: the patient is a 77 year-old female with a past medical history of coronary artery disease status post right coronary artery stent ([**10-29**]), diabetes mellitus, hypertension, deep venous thrombosis, status post recent axillobifemoral bypass graft on [**2121-5-6**] who is transferred to the [**hospital1 69**] from [**hospital3 **] with fever and arrhythmia. the patient underwent a recent bypass surgery for blue toe syndrome and course was complicated by a polymicrobial groin site infection, which included methicillin resistant staphylococcus aureus for which the patient was treated with one week of vancomycin and two weeks of po linezolid. her course is also complicated by complete heart block necessitating the placement of a ddd pacemaker, which was placed on the [**11-12**]. the patient returned to [**hospital3 **] on the [**11-10**] with a one week history of shortness of breath, fatigue, fevers or chills, sweats and right sided chest pain. at [**location (un) **] she was found to have six out of six bottles that grew out coag positive staph aureus. she was initially started on vancomycin and ceftriaxone on the [**11-10**]. in addition, the patient was noted to have a rapid irregular heart rhythm that was thought to be rapid atrial fibrillation and was loaded with intravenous amiodarone. the [**hospital 228**] [**hospital3 **] course is also notable for a 2 unit packed red blood cell transfusion for a hematocrit of 24 in the setting of guaiac positive stools and an inr of greater then 8.0. review of symptoms: fatigue, malaise, chest pain centered around the pacemaker insertion as well as dyspnea on exertion, stable three pillow orthopnea and stable lower extremity edema. the patient denies any paroxysmal nocturnal dyspnea or syncope. past medical history: coronary artery disease status post right coronary artery cypher stent on [**10/2120**] (one vessel disease). peripheral vascular disease status post axillobifemoral bypass graft [**2121-5-6**]. childhood [**last name (un) 12132**] fever. hypertension. hypercholesterolemia. diabetes mellitus complicated by neuropathy. pancytopenia (? caused by nexium). acute pancreatitis [**3-/2121**], endoscopic retrograde cholangiopancreatography demonstrated a common bile duct dilatation/stricture. she is status post sphincterotomy. cirrhosis noted incidentally on mr of [**2-27**]. the patient is hepatitis b and c seronegative. etiology of the cirrhosis is not known. status post cholecystectomy. atrophic left kidney. barrett's esophagus. gastroesophageal reflux disease/hiatal hernia. colonic polyps. oa. anxiety/panic attacks. breast cancer status post left mastectomy. suprarenal abdominal aortic aneurysm that is 4.2 cm in size. as mentioned the patient is status post ddd pacemaker placement on the [**2121-5-12**] for complete heart block. medications on transfer: 1. ceftriaxone 1 gram intravenously q day. 2. aspirin 81. 3. lopressor 5 intravenously q 6. 4. protonix. 5. regular insulin sliding scale. 6. vancomycin q 48 hours. 7. intravenous heparin. social history: the patient does not smoke. she denies current ethanol use. denies any ivda. the patient lives alone. family history: the patient is adopted and family history is noncontributory. physical examination on admission: temperature 98.9, blood pressure 105/48, heart rate 90, respiratory rate 27 with an o2 sat of 98 percent on 4 liters. the patient is found lying flat in bed breathing comfortably in no acute distress, anicteric. conjunctiva are uninjected. pupils are equal, round and reactive to light. extraocular movements intact. mucous membranes are moist. there are no sores or lesions in the oropharynx. there is no jugular venous distension in the upright position. the patient has an irregular rhythm with a grade 2 out of 6 holosystolic murmur best heard at the apex radiating to the axilla. there is a normal s1 and s2. no s3 or s4 are appreciated. the patient has bilateral crackles one half of the way up. abdomen is soft, nontender, nondistended. positive bowel sounds. she has 1 plus pitting edema bilaterally. she has 1 plus dorsalis pedis pulses and trace posterior tibial pulses bilaterally. there are no rashes noted and no stigmata of endocarditis appreciated on examination. neurological examination mental status the patient is alert, oriented times three. she has a flat affect. cranial nerve examination is notable for moderate hearing loss, otherwise unremarkable. upper and lower extremity strength 4 to 5 plus and symmetric bilaterally. normal cerebellar examination. gait is not tested. laboratories on admission: sodium 130, potassium 8.7, chloride 95, bicarb 21, bun 58 creatinine 2.1, glucose 248, white blood cell count 5 with a hematocrit of 28 and platelets of 86. electrocardiogram demonstrates a paced rhythm with atrial premature complexes, left atrial abnormality, left bundle branch block with an intraventricular conduction delay. hospital course: 1. infectious disease: as mentioned above the patient was noted to have a high grade bacteremia from cultures drawn at the [**hospital3 **] prior to admission. surveillance cultures following transfer continued to reveal high grade bacteremia with 2 out of 4 bottles that were positive on the 15th for gram positive cocci. they were identified as mrsa. the patient was continued on intravenous vancomycin on a renally dosed basis. given the discomfort around her pacemaker site as well as fluctuance at the pacemaker site, as well as her frequent arrhythmia the electrophysiology service was consulted. subsequent ecg on the [**5-11**] showed what was likely to be a wide complex tachycardia with a left bundle branch block, superior axis with av dissociation consistent with ventricular tachycardia. she was subsequently noted to have multiple prolonged runs of wide complex tachycardia of 10 to 30 beats on telemetry. interrogation of pacemaker demonstrated multiple runs of ventricular tachycardia. chest film demonstrated that the a lead is well placed and the v lead had become dislodged. subsequent fluoroscopy revealed that the v lead was dislodged and located in the rvot (had been placed in the rva). the decision was made to remove the pacemaker given lead dislodgement and also about of concern for likely pacemaker infection. an incision was made over the generator and a moderate amount of brown fluid was expressed from the pocket. fluid was sent for studies and revealed involvement with mrsa. pocket was extensively irrigated with antibiotic solution (gentamycin and vancomycin) and was debrided of necrotic appearing tissue. a penrose drain was placed in the wound and the tissue was approximated, but not closed. out of concern for possible endocarditis given the combination of high grade mrsa bacteremia, likely infected pacer wire, which is present in the rv and rvot as well as newly appreciated mr murmur, the patient underwent transesophageal echocardiogram, which did reveal mild to moderate mitral regurgitation as well as moderate mitral annular calcification. an echogenic mass was seen at the base of the posterior mitral valve leaflet consistent with a calcified annulus, however, a vegetation in his region could not be fully excluded. given the history of groin infection that included involvement with mrsa shortly after the axillobifemoral graft was placed as well as the high grade mrsa bacteremia, the patient was taken for mr of the torso to ascertain whether the axillobifemoral graft might be infected. the mri revealed the graft is patent with patent proxima and distal anastomosis though with a large amount of fluid along entire extent of the graft that is up to 3 cm in transverse diameter in portions. the fluid is contained within an enhancing capsule that is highly concerning for infectious involvement. the patient is to undergo ultrasound guided diagnostic tap of this perigraft fluid on the [**5-18**]. the patient's surveillance cultures had been negative since the [**5-12**] through the time of this dictation summary. the patient also complained of low back pain and again given the history of high grade mrsa bacteremia the patient underwent mr of the l spine. although initially the mri was concerning for l5 s1 facet joint septic arthritis and possible associated epidural abscess a subsequent review of the mri with both neurosurgery and infectious disease consult as well as with radiology revealed a very low level of suspicion for either septic arthritis or epidural abscess. serial physical examinations were followed and there was no evidence of cord compression through the time of this dictation summary. the patient has remained afebrile for several days prior to the end of the period covered by this dictation summary. the patient has also had multiple episodes with diarrhea. three c-diff tox and asas have been negative. additional stool studies are pending at the time of this dictation summary. 1. arrythmia: as mentioned above the patient was transferred from the outside hospital with concern for possible rapid atrial fibrillation. however, further studies revealed dislodgement of the ventricular pacemaker lead and displacement into the rvot. it is felt that the arrhythmia that was noted prior to transfer and just after transfer were likely caused by this malfunctioning lead, which stimulated a burst of wide complex tachycardia. the pacemaker was removed on the [**5-11**]. the patient's amiodarone was discontinued and the patient was maintained on telemetry in the cardiac intensive care unit. the patient's status is also followed with daily ecgs. she was noted to have frequent episodes of sinus beats followed by blocked apcs. after pauses caused by the blocked apcs she was noted to have inappropriate qt prolongation of up to over 600 milliseconds and on several occasions underwent a torsad like nonsustained ventricular tachycardia of up to five beats. the patient was also noted on several electrocardiograms to have inappropriate qt prolongation. the patient's potassium and magnesium were aggressively repleated with a goal potassium greater then 4.5 and a goal magnesium greater then 2.5. the patient's ssri was titrated off. the patient was maintained on beta blocker and the dose of beta blocker was titrated upwards to help prevent phase three blocking. out of concern for reinfection of even a temporary pacemaker wire the patient was maintained on telemetry without reinsertion of pacing wire and remained hemodynamically stable even during the short burst of torsad like nonsustained ventricular tachycardia. 1. coronary artery disease: the patient was maintained on aspirin, ace inhibitor and lipitor. she was noted to have dynamic t wave changes on several ecgs, though remained chest pain free throughout. of note the patient was noted to have a positive troponin t on admission. although her ck maximum is 111 on the [**5-10**] troponin t was .32 and subsequently 0.35 on the [**5-11**]. however, on transesophageal echocardiogram left ventricular wall motion was normal with an ef of 65 percent and rv wall motion was likewise normal. 1. congestive heart failure: the patient was noted to have significant pulmonary edema on physical examination on admission. she was gently diuresed and rapidly improved to the point that she was stable with o2 sats in the upper 90s on room air. 1. right sided visual loss: the patient complained of partial right sided visual defect several days into the hospital course. these visual defects were quite concerning to the team for possible stigmata of endocarditis. the defects are further concerning as the patient is maintained on anticoagulation for her bypass graft and had an elevated inr of greater then 8 prior to admission. an mr of the head did not demonstrate any evidence for septic emboli, although there was concern for a small (.5 cm) subdural hematoma in the right occipital region. however, subsequent ct did not demonstrate any intra or extracranial hemorrhage. an ophthalmology consultation was obtained and a dilated examination was performed. the patient was observed to have had a small retinal hemorrhage. the hemorrhage was thought to be unrelated to the mrsa infection and was felt to be self limited. the patient's visual examination was noted to be stable on subsequent serial examinations. 1. diabetes mellitus: the patient was continued on a humalog sliding scale and her dose of q.h.s. glargine was titrated upwards. 1. depression: the patient was continued on her outpatient dose of sertraline. the dose was initially increased from 25 mg q day to 50 mg q day, though when the patient had qt prolongation of uncertain etiology the patient's sertraline was discontinued. 1. pancytopenia: the patient was noted to have pancytopenia on admission. this had previously been attributed to a possible adverse reaction to nexium. the patient does, however, have a history of gastroesophageal reflux disease as well as barrett's esophagus and was maintained on an h2 blocker rather then protonix or nexium. the patient's white blood cell, hematocrit and platelet count all increased over the period of this dictation. 1. acute renal failure: the patient was noted to have arf on admission with a creatinine of 2.1 on admission. this is a significant increase from her baseline at 0.9 to 1.0. however, her creatinine subsequently improved serially to a level of 0.9 on the [**5-15**]. this dictation summary will cover the hospital course through the [**5-17**]. the remainder of the [**hospital 228**] hospital course will be dictated subsequently. [**first name11 (name pattern1) **] [**last name (namepattern1) **], md [**md number(2) 12421**] dictated by:[**last name (namepattern1) 8188**] medquist36 d: [**2121-6-18**] 02:02:10 t: [**2121-6-18**] 06:36:49 job#: [**job number **]",1
72,"admission date: [**2118-3-15**] discharge date: [**2118-3-18**] date of birth: [**2048-8-25**] sex: f service: medicine allergies: penicillins / iodine / sulfa (sulfonamides) attending:[**first name3 (lf) 3016**] chief complaint: syncope, adverse reaction to taxotere major surgical or invasive procedure: port-a-cath placement history of present illness: ms. [**known lastname **] is a 69 y/o f with h/o breast cancer s/p r partial mastectomy, + nodal resection (only sentinel node positive) currently on adjuvant therapy, who presented for scheduled outpatient administration of taxotere cycle 2 yesterday and had syncope and hypotension 40 minutes into infusion. she reports that she was in her usual state of health, no recent fever or other symptoms prior to starting treatment. forty minutes into infusion per report she became hypoxemic, bradycardic and then decrease mental status. she only remebers feeling like she had warmth in her mouth, taking a sip of water and then waking up surrounded by people. bp recorded sbp 60's, transiently bradycardic, then hr into the 160's. she received iv fluids and benadryl 50 iv. she denies chest pain, palpitations, head aches, dyspnea, wheezing, chest heaviness, abdominal pain or other significant symptoms. . she was admitted to the micu and monitored overnight. in icu, she was noted to be hypothermic, warmed, also received benadryl, hydrocortisone. weaned off non re-breather to room air within 30minutes. she ruled out for mi by cardiac enzymes. . currently she reports a slight headache but otherwise denies any complaints. past medical history: hypertension hypercholesterolemia lumbar disc spinal fusion anxiety bilateral cataracts s/p hemicolectomy post diverticulitis. recent dx r breast cancer s/p surgery [**2118-1-25**] with positive lymph nodes. axilary disection and reexcision. her-2 neu negative er and pr + social history: patient retired elementary school teacher. widowed. 1 son smoked +, quitted 30-35 years ago. denied alcohol family history: non contributory physical exam: vitals: t:97.5 p:94 r:20 bp: 143/46 sao2: 98%ra general: awake, alert, nad heent: moist oral mucose, no oral lesions pulmonary: ctab, no wheezing/crackles cardiac: rrr, s1s2 no murmurs abdomen: soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted. extremities: no edema, no calf tenderness, warm dp's 2+b skin: no rashes or lesions noted. neurologic: alert, oriented x3 pertinent results: [**2118-3-18**] bone scan: 1. no findings suspicious for metastatic disease. 2. degenerative changes of the thoracic and lumbar spines, more prominnent atl2-l3. 3. atherosclerotic calcifications. 4. 5 mm left upper lobe nodule. recommend follow up chest ct in 6 months. . [**2118-3-16**] echo: the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. left ventricular systolic function is hyperdynamic (ef>75%). there is a mild resting left ventricular outflow tract obstruction. the gradient increased with the valsalva manuever. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. the estimated pulmonary artery systolic pressure is normal. there is a minimally increased gradient consistent with trivial pulmonic valve stenosis. there is a trivial/physiologic pericardial effusion. there are no echocardiographic signs of tamponade. . [**2118-3-16**] mri head: 1. no intracranial metastasis. 2. nine-mm enhancing extra-axial mass of the anterior falx cerebri, which most likely represents a meningioma. 3. signal abnormality of the c4 vertebral body which may represent metastasis. . labs on discharge: [**2118-3-15**] 12:00pm blood wbc-11.0# rbc-3.69* hgb-11.1* hct-31.1* mcv-84 mch-30.0 mchc-35.7* rdw-13.2 plt ct-394 [**2118-3-18**] 09:17am blood wbc-6.4# rbc-3.58* hgb-11.0* hct-30.7* mcv-86 mch-30.6 mchc-35.7* rdw-13.8 plt ct-493* [**2118-3-15**] 05:51pm blood glucose-121* urean-19 creat-0.8 na-134 k-3.6 cl-97 hco3-21* angap-20 [**2118-3-18**] 09:17am blood glucose-106* urean-12 creat-0.8 na-135 k-4.1 cl-100 hco3-26 angap-13 [**2118-3-15**] 05:51pm blood tsh-0.38 [**2118-3-17**] 07:10am blood calcium-9.4 phos-2.5* mg-1.8 brief hospital course: ms. [**known lastname **] is a 69 y/o female with h/o htn, recently dx breast cancer s/p r lumpectomy and nodal disection, + sentinal node now on adjuvant chemotherapy who had syncopal episode while getting infusion of taxetere. 1) syncope/hypotension: most likely adverse reaction to taxetere which was infusing during the time that she had the event. other major cosideration would be cardiac dysrhythmia or mi, however she ruled out for mi with no events on telemetry. she had an echocardiogram showing mild diastolic dysfunction, ef >75%, no cause for syncope. she also had an mri of her head which did not show any acute pathology. she had no further events during her hospitalization. 2)breast cancer: given syncopal event treatment with taxetere will be stopped and she will be switched to an alternative chemotheraputic regimen to complete her adjuvant therapy. mri of head during admission showed signal abnormality of the c4 vertebral body which was concerning for possible metastasis. she had a bone scan to follow up the mri which did not show any evidence of metastatic disease. she had port placed placed during her admission for future access/chemo. she will follow up with dr. [**last name (stitle) **] in clinic. 3)hypertension: normotensive, she was continued on enalapril. 4) hypercholesterolemia: continue simvastatin 5)anxiety -continue home dose alprazolam 6)pain - she was continued on home regimen of tylenol 1000mg q6hr prn, home dose oxycontin 20mg qam (per pt only takes once per day). medications on admission: alprazolam 1-1.5mg four times daily dexamethasone 8mg [**hospital1 **] on the day before, day of and day after chemo enlapril 20 mg qd fluticasone 50 2 sprays each nostril [**hospital1 **] vicodin prn for pain lorazepam 0.5mg q8hours as needed for nausea boniva 2.5mg tab qmonth naproxen 500mg [**hospital1 **] ondansetron 8mg tid for 2 days after chemo oxycontin 20mg daily neulasta 1 sc 24 hours after chemo donnatal 16.2mg [**12-22**] by mouth daily compazine 10mg q8 hours prn nausea ranitidine 150 daily simvastatin 10 mg tab qd dyazide 37.5/25 one daily extra-strength tylenol 2 tabs q6h prn colace 100mg [**1-24**] [**hospital1 **] prn calcium carbonate vit d 1 tab day loratadine 10 mg tab daily senna [**12-22**] tab [**hospital1 **] discharge medications: 1. alprazolam 0.25 mg tablet sig: six (6) tablet po qid (4 times a day) as needed. 2. enalapril maleate 10 mg tablet sig: two (2) tablet po daily (daily). 3. fluticasone 50 mcg/actuation spray, suspension sig: one (1) spray nasal daily (daily). 4. boniva 2.5 mg tablet sig: one (1) tablet po once a month. 5. oxycodone 20 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po qam (once a day (in the morning)). 6. loratadine 10 mg tablet sig: one (1) tablet po once a day. 7. docusate sodium 100 mg capsule sig: two (2) capsule po bid (2 times a day). 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 9. simvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 10. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day). 11. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q8h (every 8 hours) as needed. 12. naproxen 500 mg tablet sig: one (1) tablet po twice a day. 13. compazine 10 mg tablet sig: one (1) tablet po every eight (8) hours as needed for nausea. 14. donnatal 16.2 mg tablet sig: 1-2 tablets po once a day. 15. dyazide 37.5-25 mg capsule sig: one (1) capsule po once a day. 16. calcium 500 with d 500 (1,250)-400 mg-unit tablet sig: one (1) tablet po once a day. 17. acetaminophen 500 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed. discharge disposition: home discharge diagnosis: syncope taxotere adverse reaction . breast cancer s/p right partial mastectomy and lymph node dissection hypertension hypercholesterolemia s/p hemicolectomy for diverticulitis discharge condition: fair discharge instructions: you were admitted to the hospital after you lost consciousness while getting your chemotherapy infusion. you were monitored in the icu and then on the oncology floor. you had blood tests which did not show any evidece of a [**last name **] problem or infection as a cause of her symptoms. you had a heart ultrasound which did not show any significant abnormalities of your heart. you also had bone scan as well which you can follow up with dr. [**last name (stitle) **] for the results. a port was placed during your admission for future access and chemotherapy treatment. none of your home medications were changed. please follow up as below. please call your doctor or return to the hospital if you experience any concerning symptoms including fevers, chest pain, difficulty breathing, light headedness, fainting or any other concerning symptoms. followup instructions: you have follow up scheduled as below: provider: [**first name8 (namepattern2) **] [**first name8 (namepattern2) **] [**name12 (nameis) **], md phone:[**telephone/fax (1) 22**] date/time:[**2118-4-5**] 12:00 provider: [**first name4 (namepattern1) 4617**] [**last name (namepattern1) 4618**], rn phone:[**telephone/fax (1) 22**] date/time:[**2118-4-5**] 1:00 . please call your primary care doctor, dr. [**last name (stitle) 32496**] at [**telephone/fax (1) 58523**] and schedule an appointment to be seen within one to two weeks of discharge. [**name6 (md) **] [**name8 (md) 831**] md, [**doctor first name 3018**]",1
73,"admission date: [**2166-12-10**] discharge date: [**2167-1-2**] date of birth: [**2123-9-19**] sex: f service: medicine allergies: penicillins / dilantin attending:[**first name3 (lf) 358**] chief complaint: vomiting/confused major surgical or invasive procedure: 1/24 l mca coiling and evd placement history of present illness: hpi: (history obtained from boyfriend) 43 year old female presents to the er today after feeling sick since saturday. she vomited on saturday and the family thought she had a virus. the patient refused to eat and seemed confused today so her boyfriend called 911. she was brought to [**hospital1 18**] where a ct scan shows a left frontal ich with extension in the ventricles. the patient does report a headache currently. she does not have any dizziness, numbness, tingling anywhere. past medical history: pmhx:unknown social history: social hx: works as a tech in this hospital family history: unknown physical exam: physical exam: t:98.8 bp:125/64 hr:54 rr:20 o2sats:99% 3l nc gen: patient is sleepy, confused as to why she is here. heent: pupils: perrl eoms-intact neck: supple. lungs: cta bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, flat affect. orientation: oriented to person, place, and year. she thought is was [**11-6**]. language: speech is slowed. naming intact. no dysarthria or paraphasic errors. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 3 to 1 mm bilaterally. visual fields are full to confrontation. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. [**doctor first name 81**]: sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. strength full power [**3-23**] throughout except hamstrings on right [**2-21**]. no pronator drift. sensation: intact to light touch bilaterally. pertinent results: ct head: preliminary report !! wet read !! (findings just rev'd, w/drs. [**last name (stitle) **] and [**name5 (ptitle) 3271**], in detail.) lrg, acute parench bleed, centered l frontal deep [**male first name (un) 4746**], w/sign assoc vasogen edema. process appears centered on 12 mm round, rel hyperdense lesion: ?aneurysm/?mass. bld dissects into ventric chain, w/early [**last name (un) **] hydroceph and dil temp horns. min shift of midline; no evid herniation. labs: pt: 13.4 ptt: 23.6 inr: 1.1 na 142 cl 106 bun 25 glu 112 k 4.0 co2 22 cr 0.6 wbc 15.7 hbg 14.3 hct 39.5 plts 323 n:83.8 l:11.9 m:3.6 e:0.3 bas:0.4 brief hospital course: a/p: 43 yo woman with left mca aneurysm rupture. . hospital course: . patient was admitted from ed to neuro icu for q1 hour neuro checks. she had cta/mra/mri which showed evolving l iph of l basal ganglia and frontal lobe with ivh and evidence of obstructive hydrocephalus. she had a l mca coiling performed and an external ventricular drain placed on [**12-11**]. started on cefazolin as prophylaxis for the drain. she remained intubated until pod 3. she spiked a temperature on pod3. pan cultures and csf sent. csf was concerning for infection with 250 wbcs. started on empiric vancomycin and ceftriaxone. infectious disease was consulted and recommended cipro and c.diff checks. continued to spike temps over her hospitalization and multiple blood, csf, and urine cx have been negative except for two urine cx's that grew gpr and lactobacillus. uti's treated appropriately but continued to spike fevers. mri was not concerning for infection. eventually it was decided to hold abx for a presumed drug fever. after stopping antibiotics patient remained afebrile. she had hyponatremia and leukopenia on labs. patient was fluid restricted and started on salt tabs. patient's hct then steadily declined no source defined - guaiac negative. her neuro exam markedly improved and was doing very well with physical therapy. patient was transferred to medicine service for workup of anemia and treatment of metabolic issues. . on the medicine service: . # leukopenia: the patient had a leukopenia on transfer. an anc was checked when the wbc dropped to 1.8, with an anc of 700. etiology of leukopenia was likely lab error versus medication effect (keppra, vancomycin). she will have her wbc monitored as an outpatient. . # anemia: on the day of transfer from neurosurgery, she was noted to have a 10-point hct drop from 30 to 20. this drop was from lab error, as the repeat check was 26%. hemolysis labs were negative and reticulocytes were normal with an retic index of 1.8. there was no sign of bleeding and she was guaiac negative. . # aneurysm rupture: was stable on transfer. coil stable without new pathology seen on mri/mra [**12-24**]. patient's memory and weakness deficits were improving daily per boyfriend's report. the nimodipine was discontinued on [**1-2**] and the keppra was continued (will be on this until 1 month follow-up with neurosurgery. she was discharged on plavix 75 mg po qday and aspirin for coil per neurosurgery directions. she was asked to arrange a follow-up mri/mra in one month and then see dr. [**first name (stitle) **] after that. . # right-hand weakness/cognitive deficits: improving per patient and boyfriend. only minimal weakness noted on exam with wrist extensors, all other strength was equal bilaterally. patient is right handed and was still having significant difficulty writing at the time of discharge. per ot notes, the patient's rue function was improving and recommended outpatient rehab as soon as appropriate. concerning the cognitive function, she was not at baseline at the time of discharge. she had improved during her hospitalization but experienced delayed responses and speech. she was discharged with plans for outpatient ot, pt and speech therapy. . # anorexia: patient reported having no appetite since the aneurysm bleed, but eating because she knows she needs to eat. likely related to the aneurysm rupture, and should improve with time. considered an appetite stimulant and suggested starting as an outpatient is appetite did not improve. did not appear to be secondary to depression. she was encouraged to take in high calorie, smaller meals supplemented with ensure. weight was stable. . # dvt: right calf vein dvt at the level of the peroneal vein seen on doppler on [**12-24**]. on transfer to medicine was on asa, plavix, and sq heparin. neurosurgery requested that she not be started on coumadin for now, but aggreed to theraputic lovenox for a course of [**1-22**] months. she will continue lovenox until her neurosurgery follow-up visit and the issue of coumadin transition can be discussed at that time. medications on admission: medications prior to admission: unknown discharge medications: 1. outpatient occupational therapy 2. outpatient physical therapy 3. outpatient speech/swallowing therapy 4. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 5. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily) for 7 days. disp:*7 tablet(s)* refills:*0* 6. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*1* 7. enoxaparin 80 mg/0.8 ml syringe sig: one (1) 80mg syringe subcutaneous q12h (every 12 hours). disp:*60 80mg syringe* refills:*1* 8. acetaminophen 500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 9. outpatient lab work cbc lfts within 1-2 weeks. have results send to: reymond,[**last name (un) 76114**] k [**telephone/fax (1) 76115**] discharge disposition: home with service facility: [**location (un) 86**] vna discharge diagnosis: primary: 1. left mca aneurysm rupture 2. deep vein thrombosis 3. hyperglycemia 4. hyponatremia 5. adverse reaction to antibiotics (cephalosporins) 6. anemia 7. leukopenia 8. anorexia discharge condition: improved: vital signs stable, right hand weakness improving, cognitive function improving. discharge instructions: you were admitted to the hospital for a ruptured brain anurysm. the aneurysm was coiled and the bleeding was stopped. you developed post-op fever and were treated with antibiotics for suspected infection. these antibiotics were stopped when you developed a rash. the rash was likely due to ceftriaxone or ceftazidime, both of which are part of a group of medications called cephalosporins. you should not take cephalosporins for infection in the future. your cognitive deficits have improved since the aneurysm bleeding was stopped and your right arm/hand weakness is improving. you were started on an antiseizure medication (keppra) due to the bleed and will need to take this until directed to stop by your neurosurgeon. for the coil, you were also started on aspirin and plavix. you will continue to the aspirin indefinetely. you will take the plavix for one more week and then can stop this medication. it was discovered that you developed a dvt in your right leg. you were started on a blood thinning medication (lovenox) and will need to take this until directed to stop. 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 and/or staples have been removed ?????? you may shower before this time with assistance and use of a shower cap ?????? increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, ibuprofen etc. ?????? if you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? clearance to drive and return to work will be addressed at your post-operative office visit call your surgeon immediately if you experience any of the following: ?????? new onset of tremors or seizures ?????? any confusion or change in mental status ?????? any numbness, tingling, weakness in your extremities ?????? pain or headache that is continually increasing or not relieved by pain medication ?????? any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? fever greater than or equal to 101?????? f followup instructions: please call [**telephone/fax (1) **] to schedule an appointment with dr. [**first name (stitle) **] to have an angiographic study performed in one month to assess your aneurysm. you will need to schedule an appointment to meet with him after this imaging study has been performed. you will need a cat scan of the brain without contrast. you will/will not need an mri of the brain with or without gadolidium please follow-up with your primary care doctor in [**11-19**] weeks regarding your hospitalization. you should have a cbc and lfts drawn at you follow-up appointment with your pcp. completed by:[**2167-1-10**]",1
74,"admission date: [**2101-3-17**] discharge date: [**2101-3-25**] date of birth: [**2029-1-21**] sex: f service: cardiothoracic history of present illness: mrs. [**known lastname **] is a 72 year old woman admitted to the [**hospital6 33**] on [**3-15**] with the complaint of substernal chest pain. she had a positive ett done on [**3-16**] with ischemic changes. a subsequently cardiac catheterization revealed 40% left main and three vessel disease with a normal ejection fraction. she was transferred to [**hospital1 69**] for coronary artery bypass grafting. past medical history: 1. significant for hypercholesterolemia. 2. hypertension. 3. degenerative joint disease. 4. status post right total hip replacement status post hysterectomy. social history: married and lives with husband. denies tobacco use; denies alcohol use. medications at home: 1. hydrochlorothiazide 25 mg q. day. medications at [**hospital6 **]: 1. lopressor 25 mg twice a day. 2. aspirin 325 q. day. 3. hydrochlorothiazide 25 mg q. day. 4. lipitor, no dose. 5. lovenox 0.7 twice a day. 6. xanax 0.25 p.r.n. allergies: include penicillin, sulfa, erythromycin, lisinopril, atenolol and donnatal. the patient is unsure of adverse reactions. she states that she can only tolerate enteric coated aspirin. laboratory: pt 12.4, ptt 29.0, inr 0.9. sodium 143, potassium 3.7, chloride 103, co2 29, bun 17, creatinine 0.7, glucose 85. white blood cell count 5.8, hematocrit 43.1, platelets 252. review of systems: neurological: occasional migraines. no cerebrovascular accidents, transient ischemic attacks or seizures. pulmonary: no asthma, cough. positive dyspnea on exertion. cardiovascular: chest pain with exertion. no paroxysmal nocturnal dyspnea, no orthopnea. gi: rare acid reflux. no diarrhea, constipation, nausea or vomiting. genitourinary: no frequency, no dysuria. endocrine: no diabetes mellitus, no thyroid problems. [**name (ni) **] hematological issues. musculoskeletal: chronic back and neck pain. physical examination: in general, this is a 72 year old woman lying in bed in no acute distress. neurological grossly intact. no carotid bruits noted. pulmonary with lungs clear to auscultation bilaterally. cardiac is regular rate and rhythm with no murmur noted. abdomen is obese, soft, nontender, positive bowel sounds. extremities with bilateral varicosities, left greater than right. hospital course: the patient was admitted to [**hospital1 346**] and followed by the medicine service with cardiology consultation. on [**3-21**], she was brought to the operating room where she underwent coronary artery bypass grafting times four. please see the operative report for full details. in summary, she had a coronary artery bypass graft times four with the left internal mammary artery to the left anterior descending, saphenous vein graft to the ramus, saphenous vein graft to the obtuse marginal, saphenous vein graft to the right coronary artery. her bypass time was 73 minutes with a cross clamp time of 64 minutes. she tolerated the operation well and was transferred from the operating room to the cardiac intensive care unit. at the time of transfer, her mean arterial pressure was 90 with a cvp of 11. she was a-paced at 88 beats per minute. she had nitroglycerin at 1 mic kilogram per minute and propofol at 30 mics per kilogram per minute. she did well in the immediate postoperative period. her anesthesia was reversed. she was weaned from the ventilator and successfully extubated. she remained hemodynamically stable on the operative day with neo-synephrine infusion. on postoperative day one, she remained hemodynamically stable. her chest tubes were discontinued. her neo-synephrine was weaned to off and she was transferred to [**hospital ward name 7717**] for continuing postoperative care and cardiac rehabilitation. on [**hospital ward name 7717**] the patient remained hemodynamically stable. she was started on beta blockade as well as diuretics. over the course of the next several days, her activity level was advanced with the assistance of the nursing staff and physical therapy. her stay on [**hospital ward name 7717**] was uneventful. on postoperative day four, it was decided that the patient was stable and ready to be discharged to home. at the time of discharge, the patient's physical examination is as follows: vital signs with temperature of 97.3 f.; heart rate 77 in sinus rhythm; blood pressure 100/50; respiratory rate 14; o2 saturation 93% on room air. weigh preoperatively 72.5 kilos and at discharge 71.5 kilos. laboratory data revealed white blood cell count of 6.7, hematocrit 27.2, platelets 247. sodium 142, potassium 3.7, chloride 107, co2 27, bun 12, creatinine 0.8, glucose 92. on physical examination she was alert and oriented times three. moves all extremities and follows commands. breath sounds with scattered rhonchi throughout. cardiac is regular rate and rhythm, s1, s2, with no murmurs. sternum is stable. incision with staples, open to air, clean and dry. abdomen is soft, nontender, nondistended with positive bowel sounds. extremities are warm and well perfused with one to two plus edema bilaterally, right slightly greater than left. right leg incision with steri-strips, open to air, clean and dry. discharge medications: 1. lasix 20 mg p.o. q. day times ten days. 2. potassium 20 meq q. day times ten days. 3. aspirin 325 mg q. day. 4. plavix 75 mg q. day. 5. atorvastatin 10 q. day. 6. metoprolol 25 twice a day. 7. dilaudid 2 to 4 mg q. four hours p.r.n. condition at discharge: good. discharge diagnoses: 1. coronary artery disease status post coronary artery bypass graft times four. 2. hypercholesterolemia. 3. hypertension. 4. degenerative joint disease. 5. status post right total hip replacement. 6. status post hysterectomy. discharge instructions: 1. the patient is to be discharged home with [**hospital6 1587**] services. 2. she is to have follow-up in the [**hospital 409**] clinic in two weeks. 3. follow-up with dr. [**last name (stitle) 13175**] and/or [**last name (un) **] in three weeks. 4. follow-up with dr. [**last name (stitle) **] in four weeks. [**first name11 (name pattern1) 1112**] [**last name (namepattern1) **], m.d. [**md number(1) 3113**] dictated by: [**first name8 (namepattern2) 251**] [**name8 (md) **], np medquist36 d: [**2101-3-25**] 17:21 t: [**2101-3-25**] 19:04 job#: [**job number 52860**]",1
75,"admission date: [**2150-10-12**] discharge date: [**2150-10-15**] date of birth: [**2090-6-27**] sex: f service: medicine allergies: penicillins / ceclor / cefoxitin / tetracycline / codeine / demerol / clindamycin / moxifloxacin attending:[**first name3 (lf) 2291**] chief complaint: meningitis major surgical or invasive procedure: none history of present illness: history of present illness: this is a 60 year old female with a history of auto immune mediated myelitis initiated on ivig on [**2150-10-9**]. she presented to [**hospital3 4107**] with 2 day history of headache initially responsive to advil. yesterday she awoke with severe headache and chills, with the development of nausea and emesis. she also had blurry vision. due to the severity of her symptoms she called her neurologist who recommended ed evaluation. at [**first name4 (namepattern1) **] [**last name (namepattern1) **] an lp was performed which showed 60 red cells and 600wbcs in tube 4, glucose 62 and protein 114 with negative gram stain. fluid was clear and colorless. a head ct was negative and a cxr showed a rll infiltrate. she was given a dose of vancomycin and anzithromycin and sent to [**hospital1 **] for further management given history of multiple antibiotic allergies. in the [**hospital1 **] ed initial vs were t 97.7 hr 80 bp 97/57 02 98% ra rr 20. blood cultures were sent. she was noted to have nuchal rigidity and she was given acyclovir and tylenol. id was consulted with recommendation for iv bactrim and iv meropenem in icu setting. typically flares once a year with autoimmune myeltis, with 2 flares this year. over last month symptoms have worsened with joint pain and neuropathy, weakness, constipation, poor apetite. got ivig x 1 on [**2150-10-9**] with plan for 4 additional treatments weekly with decadron, zofran given. muscle weakness improved but 2 days later pt had worsened headache with photophobia, with nausea and non bloody emesis. had neck stiffness yesterday. no recent travel. past medical history: autoimmune mediated myelitis diagnosed in 94 partial complex seizure disorder last a couple of weeks ago severe glaucoma cervical spondylitis depression asthma social history: lives with her daughter and husband. does not drink etoh. quit smoking years ago. denies illicits. retired nurse. family history: no history of seizure daughter: dm mother: dm, stroke age 47 multiple family members with cad brother with cerebral palsy, 2nd brother with [**name2 (ni) **] palsy sister with rheumatoid arthritis, sister with asthma physical exam: physical exam on admission: general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact physical exam on discharge: vs - 98.1, 98.7, 95-122/42-80 (currently 99/65), 67, 18, 96% general - well-appearing female in nad, comfortable, appropriate heent - nc/at, perrl, eomi, glasses in place, sclerae anicteric, mmm, op clear neck - supple, no thyromegaly, no jvd, no nuchal rigidity lungs - cta bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use heart - 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 neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength [**5-30**] throughout, sensation grossly intact throughout, cerebellar exam intact (however patient with some difficulty on finger to nose, able to do dysdiokenesia) pertinent results: [**2150-10-12**] 01:02am plt count-179 [**2150-10-12**] 01:02am neuts-64.6 lymphs-25.2 monos-9.3 eos-0.5 basos-0.4 [**2150-10-12**] 01:02am wbc-5.7 rbc-3.52*# hgb-11.1*# hct-32.2*# mcv-92 mch-31.5 mchc-34.4 rdw-12.5 [**2150-10-12**] 01:02am glucose-98 urea n-10 creat-0.7 sodium-138 potassium-3.6 chloride-106 total co2-26 anion gap-10 [**2150-10-12**] 01:15am lactate-0.9 [**2150-10-12**] 02:15am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.5 leuk-neg [**2150-10-12**]- blood cultures pending x 2 - ngtd [**2150-10-12**]- urine culture no growth final [**2150-10-11**] [**hospital3 4107**] csf: gram stain negative, 60rbcs, 600wbcs, gram stain negative, hsv pcr-negative, culture with no growth final [**2150-10-14**] - csf: gram stain (final [**2150-10-14**]): no polymorphonuclear leukocytes seen. no microorganisms seen. no growth - prelim, final pending [**2150-10-14**] 01:47pm cerebrospinal fluid (csf) wbc-7 rbc-23* polys-1 lymphs-49 monos-8 atyps-42 [**2150-10-14**] 01:47pm cerebrospinal fluid (csf) wbc-9 rbc-17* polys-1 lymphs-71 monos-0 atyps-28 [**2150-10-14**] 01:47pm cerebrospinal fluid (csf) totprot-26 glucose-51 labs on discharge [**2150-10-14**] 05:32am blood wbc-6.2 rbc-3.87* hgb-12.2 hct-34.9* mcv-90 mch-31.6 mchc-35.0 rdw-12.7 plt ct-181 [**2150-10-14**] 10:59am blood glucose-102* urean-10 creat-1.0 na-131* k-4.3 cl-98 hco3-27 angap-10 [**2150-10-14**] 10:59am blood calcium-8.8 phos-3.2 mg-2.0 brief hospital course: 60 year old woman with history of auto immune mediated myeltiis presenting with headache now with lp suggestive of early bacterial meningitis vs aseptic meningitis admitted to [**hospital1 **] for antibiotic desensitization. acute issues: # meningitis: on admission she had nuchal rigidity and headache with symptoms evolving following exposure to ivig, with suspected adverse reaction to ivig. additionally, aseptic meningitis following ivig infusion has been reported. her initial lp could also reflect an early bacterial meningitis vs viral meningitis. although the gram stain was negative, antibiotic initiation was recommended by the infectious disease team, as some organisms such as neisseria can be slow to culture. she received iv acyclovir, vancomycin, bactrim and underwent desensitization to ceftriaxone. hsv pcr was requested from osh lp. she did develop throat swelling at higher dose of ceftriaxone and required iv solumedrol, benadryl and famotidine. the patient subsequently tolerated ceftriaxone. she was transferred to the floor on hod 2. hsv pcr was negative at osh and thus acyclovir was discontinued. the id team recommended a repeat lp and this was done. it showed no signs of infectious etiology with only 7 wbcs, no organisms or polys, and negative gram stain. antibiotics were discontinued at this time. the patient was observed for 12 hours after and was without symptoms or fever. she was discharged home with the thought that the meningitis was aseptic and secondary to adverse reaction to ivig. # autoimmune mediated myelitis: pt had acute flare of her myeltis with ivig given. she had improvement of myelitis symptoms with ivig but development of nausea and headache subsequently as well as aseptic meningitis picture, most likely an adverse reaction to ivig. this was discussed by her neurologist given that she is planned for weekly ivig. the patient was scheduled to follow up with her outpatient neurologist dr. [**last name (stitle) 9449**] for further treatment. chronic issues: # asthma: home advair was continued. # glaucoma: continued eye drops # h/o seziures: home clonazepam 1.5mg [**hospital1 **] with additional 1 mg dose at 2 pm was continued. transitional issues: - patient will follow up with outpatient neurologist regarding futher care of autoimmune myelitis. - csf culture pending. - blood cultures pending. medications on admission: klonopin 1.5 am, 1mg at 2pm then 1.5mg qpm xalitan 1 drop each eye bedtime azopt l eye 1drop three times a day advair 250/110 1 puff [**hospital1 **] allergies: ceclor-anaphylaxis cefoxitin- anaphylaxis clindamycin- rash codeine-rash demerol-hypoytension moxifloxacin -(wheeze, hypotension) tetracycline-rash scopolamine-wheeze discharge medications: 1. azopt *nf* (brinzolamide) 1 % ou tid 2. clonazepam 1.5 mg po bid 3. clonazepam 1 mg po daily at 2 pm 4. fluticasone-salmeterol diskus (250/50) 1 inh ih [**hospital1 **] 5. xalatan *nf* (latanoprost) 0.005 % ou hs discharge disposition: home discharge diagnosis: aseptic meningitis secondary to adverse reaction to ivig discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mrs. [**known lastname 19122**], you were admitted to [**hospital3 **] hospital because you were having head aches and neck stiffiness and thought to have meningitis. you were transferred here because of your history with allergies to antibiotics. we initially treated you with antibiotics. however, we now think that your symptoms are not caused by an infectious meningitis but most likely secondary to an adverse reaction to your recent ivig treatment. a repeat lp at [**hospital1 **] showed no signs of infection. it was a pleasure caring for you, your [**hospital1 **] doctors followup instructions: name: [**last name (lf) **],[**first name7 (namepattern1) **] [**initial (namepattern1) **] [**last name (namepattern4) **] location: [**hospital3 **] department: neurology address: [**apartment address(1) 57404**] [**hospital1 **], [**numeric identifier 4474**] phone: [**telephone/fax (1) 57405**] appointment: tuesday [**2150-10-20**] 4:00pm name: pa [**first name8 (namepattern2) **] [**doctor last name 3315**] address: [**location (un) **], [**hospital1 **],[**numeric identifier 20089**] phone: [**telephone/fax (1) 42923**] appointment: thursday [**2150-10-22**] 10:45am *this is a follow up appointment for your hospitalization. you will be reconnected with your primary care provider after this visit. completed by:[**2150-10-15**]",1
76,"admission date: [**2198-5-22**] discharge date: [**2198-6-13**] date of birth: [**2135-9-8**] sex: f service: medicine allergies: penicillins / cephalosporins / codeine attending:[**first name3 (lf) 783**] chief complaint: group b strep endocarditis with od endophthalmitis major surgical or invasive procedure: tee picc line placement egd history of present illness: this is a 62yo female with history of autoimmune hepatitis on chronic immunosuppression, liver cirrhosis, diabetes, copd, chronic leg swelling from previous fracture, on imuran and prednisone, transferred from osh with strep b bacteremia and endopthalmitis. the patient was initially admitted to osh on [**2198-5-17**] for diarreha, nausea, and vomiting, with fever of 102 on the day of admission. she was initially felt to have an acute gastroenteritis, mild chf, and lle cellulitis. on admission she was started on iv vanc for presumed lle cellulitis, and her other meds (including imuran and prednisone) were held. she developed acute loss of vision in her r eye on the night of admission, and mri/mra was obtained. mri showed multiple punctate bilateral embolism c/w septic emboli. she was started on heparin. neurology recommended echo and mra of the aortic arch, concluding her symptoms were c/w embolic stroke. her gastroenterologist, dr. [**last name (stitle) 62005**], recommended continuing the pts imuran and prednisone. she was also started on stress dose solu-cortef for unclear reasons (not clear if pt was hypotensive). on [**5-19**] she was started on iv gent in addition to her iv vanc. prior to transfer she was seen by opthamology who felt her sxs were consistent with endopthalmitis and needs urgent eval for vitreous tap and possible vitrectomy. of note, the pt is growing 4/4 bottles from [**5-17**] with strep agalactiae group b. cxr on [**5-17**] was c/w mild chf. esr on [**5-18**] was 75. urine cx on [**5-17**] is growing strep agalactiea. echo on [**5-21**] was suspicious for mitral valve vegetation. . past medical history: a-utoimmune hepatitis with liver cirrhosis and splenomegaly--on imuran and prednisone -grade i esophageal varices -anemia in setting of imuran -copd -depression -osteopenia -chronic sinusitus -endometrial metaplasia -l ankle arthritis social history: employed as conservation [**doctor last name 360**]. husband. two children. non smoker family history: non contributory physical exam: pe: 96.9, 130/62, 71, 18, 94%ra gen: ill appearing female laying in bed with eyes closed. heent: right eye with cloudy purulence coating [**doctor first name 2281**], pupil. scleral injection. no proptosis. able to visualize light through right eye, no movement. no papilledema left eye. vision intact on left. jvp to ear lobe. cv: iii/vi sem lusb radiating to carotids. holosystolic murmur to apex. lungs: sparse crackles at bases bilaterally ab: distended, non tender, + bs. liver not palpable. extrem: 2+ edema on right, 3+ on left. erythema over posterior aspect of calf, anteriorly to knee. non tender to palpation. chronic venous stasis changes. 2+ dp right, 1+left given edema difficult to palpate. neuro: alert and oriented x 3. eomi. cranial nerves not skin- no lesions on palms or soles, echymoses throughout body. pertinent results: [**2198-5-22**] 09:21pm glucose-175* urea n-28* creat-1.0 sodium-138 potassium-3.7 chloride-105 total co2-25 anion gap-12 [**2198-5-22**] 09:21pm estgfr-using this [**2198-5-22**] 09:21pm alt(sgpt)-20 ast(sgot)-22 alk phos-79 tot bili-3.7* [**2198-5-22**] 09:21pm calcium-8.0* phosphate-3.1 magnesium-2.3 [**2198-5-22**] 09:21pm wbc-15.9*# rbc-3.41* hgb-12.5 hct-36.3 mcv-106* mch-36.8* mchc-34.5 rdw-16.5* [**2198-5-22**] 09:21pm neuts-86.9* lymphs-5.9* monos-6.0 eos-0.1 basos-1.1 [**2198-5-22**] 09:21pm anisocyt-1+ poikilocy-1+ macrocyt-3+ [**2198-5-22**] 09:21pm plt count-130*# [**2198-5-22**] 09:21pm pt-18.9* ptt-35.4* inr(pt)-1.8* blood work [**2198-6-2**] complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct [**2198-6-2**] 07:00am 13.8* 2.58* 9.6* 28.0* 109* 37.4* 34.5 21.7* 59* source: line-picc inr 1.5 renal & glucose glucose urean creat na k cl hco3 angap [**2198-6-2**] 07:00am 139* 34* 0.7 128* 4.2 94* 31 7* enzymes & bilirubin alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili indbili [**2198-6-2**] 07:00am 34 41* 79 6.5* . [**5-24**] ct head impression: no evidence of acute intracranial hemorrhage. multiple hypodensities could be consistent with history of septic emboli. however, for specific evaluation, a contrast-enhanced ct of the brain or mri is recommended. . [**2198-5-25**] echo conclusions: no thrombus is seen in the left atrial appendage. the interatrial septum is aneurysmal, but no atrial septal defect or patent foramen ovale is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). [intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] right ventricular systolic function is normal. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. the aortic valve leaflets (3) are mildly thickened. no masses or vegetations are seen on the aortic valve. trace aortic regurgitation is seen. there is a large (1.6 x 1.5 cm) vegetation on the posterior mitral leaflet, with leaflet perforation. an associated jet of severe (4+) mitral regurgitation is seen. the anterior mitral leaflet is normal in appearance, and there is no associated mitral annular abscess. no vegetation/mass is seen on the pulmonic valve and tricuspid valve. impression: mitral valve endocarditis with posterior leaflet perforation. severe mitral regurgitation. . [**2198-5-28**] pelvis ultrasound this is a technically difficult examination. the transabdominal study is very limited due to the patient's body habitus. endovaginal examination was also technically difficult. the uterus measures 4 cm in transverse x 4.7 cm in ap x 6.5 cm in sagittal dimensions. the endometrial stripe measures 5 mm in maximum dimension. multiple heterogenous areas are identified within the uterus in the mid body which may represent fibroids. the largest of these measures less than 2 cm. the ovaries are not visualized. impression: technically difficult abdominal and transvaginal examinations in patient with normal endometrial stripe thickness and heterogenous appearance of uterus which may represent fibroids. ovaries not imaged. . [**2198-5-28**] doppler liver color & pulsed doppler son[**name (ni) **] liver: normal flow and waveforms are demonstrated within the hepatic arteries. no portal venous flow is identified within the main portal vein and the main portal vein is not well delineated. impression: 1) heterogeneous echotexture of the liver consistent with cirrhosis. no focal mass lesion identified. 2) the portal vein is not well delineated on this study. no color flow or doppler pulse is present within the expected region of the portal vein. chronic portal vein thrombus cannot be excluded. 3) cholelithiasis without evidence of cholecystitis. . repeat echo [**2198-6-7**] no significant changes from prior. . brief hospital course: this is a 62 yo pt with autoimmune hepatitis on chronic immunosuppression transferred from osh, with group b strep bacteremia, septic brain emboli, endopthalmitis, endocarditis with large mitral valve vegetation and small perforation. # endocarditis/bacteremia: the patient was initially on vancomycin and gentamycin when transferred, and placed on the sepsis protocol. as per id, gentamycin was discontinued and then was switched to penicillin 3 million units q 4 hours iv after desensitization in the micu without adverse reaction. pt was afebrile while in house, with no growth from blood cultures in house. vitreous fluid grew group b strep sensitive to vancomycin and penicillin. id followed the patient and she must remain on antibiotics for a minimum of six weeks. on id follow up on the [**6-19**], they will determine the total treatment length. a picc line was placed on [**2198-6-1**]. . # mitral valve damage: given bacteremia and probable septic emboli, as well as likely mitral vegetation on outside hospital tte, tee was performed [**5-25**]. this revealed large mitral valve vegetation with perforation and severe mitral regurgitation. cardiac surgery was immediately consulted. they followed the patient and determined she was not a surgery candidate given her multiple risk factors, including her childs b/c classification. the patient was started on lasix 20 mg po daily, and a low dose of lisinopril. her beta blocker was increased, and she tolerated these changes well until an episode of low bp(see below). prior to discharge, her nadolol was again reduced to 10 mg [**hospital1 **] and tapered off due to decreased low pressure in the setting of steroid taper. she developed hypotension 70s/doppler on [**6-6**], which did not respond appropriately to 1.5 l fluid bolus plus one unit prbcs. she was put back on stress dose steroids, all bp meds were d/c and new blood cultures were sent, with no growth. the next day, a new echo was ordered out of concern for cardiogenic shock. the results were similar to the previous one. she never became febrile or tachycardic. on [**6-7**], bp was 100s/doppler and the patient continued to be asymptomatic. she compalined of intermittent atypical chest pain, and several ekg revealed no ischemic changes. she needs to be on afterload reduction ideally, consisting of bb, ace-i and lasix, however due to her blood pressure running in the 100's systolic without any symptoms, these medications were stopped and should slowly be added back as blood pressure tolerates. patient is clinically hypervolemic with le edema and jvd, however no evidence of pulmonary fluid overload on exam. . # embolic stroke: mri/mra outside hospital with evidence of punctate lesions likely septic emboli. pt was on heparin at outside hospital, but given risk of hemorrhagic bleed into emboli, it was discontinued upon presentation to the [**hospital1 18**]. neurology followed the patient in house. she was disoriented at times but this was more consistent with hepatic encephalopathy and depression. she did not develop any neuro deficits. ct head repeated with no evidence of acute bleed. . #endophtalmitis: the patient presented with hypopyon and complete vision loss. she underwent tap and aspiration, but not vitrectomy, liquid growing strep b, and had antibiotics injected directly into the chamber: vancomycin and cefepime. ophto followed closely and they deem the r eye not salvageable. evisceration versus enucleation was planned, however the patient wished to wait. in the meantime, she was continued on eye drops recommended by ophto (see medication list). she must protect her remaining eye at all times. she has been arranged for follow up with ophto. . #hyperkalemia and hyponatremia- no evidence of adrenal failure. with hyponatremia and hyperkalemia, there was concern for adrenal insufficiency, though patient was on stress dose steroids, which were subsequently tapered to 10 mg daily iv, then started po on 80 mg, tapered down to 20 mg po daily, final goal 5 mg every other day. pharmacy was consulted about penicillin with ~30 meq daily potassium, but they did not feel that this could cause persistent hyperkalemia. the patient was previously on k sparing diuretic spironolactone which was held. the patient required [**hospital1 **] lyte checks for a few days and several doses of kayexelate. the hyperkalemia resolved 8 days prior to discharge, also in the setting of increased insulin. hyponatremia persists, and is consistent with adh derangements with concentrated urine osmolality. the patient was placed on free water restriction 1.5 liter daily. . #thrombocytopenia- platelets decreased during admission, but remained above 50 except for a value in the 40s on [**6-12**]. low platelets are in the setting of cirrhosis with compromised synthetic function (albumin 1.5). she received vitamin k sq x 3 doses. hit was positive, but serotonin release antibody was negative, therefore the patient was continued on sq heparin with no evidence of decreased platelet count or thrombosis. small amount of vaginal bleeding during admission, which resolved. . #cirrhosis: egd demonstarted grade i varices. the hepatology service followed the patient. imuran was held. nadolol was re-started at 10 [**hospital1 **], then increased to 20 [**hospital1 **]. the bb was subsequently decreased again to 10 mg in the setting of low blood pressures. aldactone was held with the development of hyperkalemia. the patient developed hepatic encephalopathy with asterixis and lactulose was begun and titrated to 3 bm daily, with the patient's mental status improving. the patient developed worsening unconjugated bilirubinemia with some evidence of hemolysis. bilirubin then trended down (although it remains elevated). transaminases remained normal with a mild elevation the last few days. hepatology started rifaximin on [**6-7**]. per hepatology, imuran can be restarted if lfts double. taper of prednisone can continue while watching her lfts. she should continue on 20 mg prednisone daily for [**6-13**] and [**6-14**] and then be decreased to 10 mg daily to be continued indefinitely. . #hemodynamics: the patient blood pressure became low on [**6-5**] and [**6-6**]. on [**6-6**], she triggered for bp 78/doppler. she was clammy on exam but not lightheaded or diaphoretic. that same day, her hct<25 with no significant bleeding (she had persistent hematuria throughout admission, insufficient to explain her hct drop). she was treated with 1500 cc ns and transfused one unit, without adequate response. she was started on stress dose hydrocortisone. after transfusion, the hct was appropriately 2 points higher. blood cultures were sent, which were negative. the next day, an echo showed no changes from prior. bp was 100s/doppler and an ekg was obtained as described above, with no ischemic changes. the patient's blood pressure stabilized and she was again placed on steroid taper 2 days later. discharge bp was 100/50, which is consistent with patient's baseline bp. . #hyperglycemia: initially the patient's sugars were 200-300s. lantus dose was increased to 32 units, then 34 and 36, and humalog as well as sliding scale was successively tightened. at discharge, the finger sticks were significantly improved, and the lantus dose is again decreased in setting of steroid taper. . #depression: initially, all psychotropic medications were held due to the patient's poor mentation in the setting of bacteremia and possibly hepatic encephalopathy. the patient's sensorium cleared significantly with treatment, however her mood became increasingly depressed. the patient endorsed feelings of hopelesness, helplessness, and deep depression. celexa was restarted on [**6-11**]. . #vaginal bleeding: the patient developed mild vaginal bleeding with stable crit. she had had a normal gyn exam and pap 4 months prior to admission. gyn was consulted and examination revealed dark blood at the cervical os. they recommend that the patient have an endometrial biopsy as an outpatient. . #funguria: two successive urine cultures revealed yeast. a decision was made to institute a short course of fluconazole (last day [**2198-6-6**]) given the patient's immunosppression. an attempt was made to d/c foley, but the patient became unable to void, and the foley was reinstituted. a spontaneous voiding trial on 5/ 5/ 07 again resulted in the patient being unable to void, therefore the foley remains in place at discharge. the patient had at all times a normal neuro exam and specifically, she did not have saddle anesthesia. . #adl: pt and ot evaluated the patient and the consensus is that she is significantly below baseline and has excellent rehab potential. the patient is severely deconditioned and has difficulty ambulating at discharge. . #fen: diabetic, cardiac diet . #ppx: ssi while on steroids, ppi, heparin sq. . #code: full . #[**name (ni) **] husband at [**telephone/fax (1) 62006**] . #dispo- to rehab. medications on admission: -imuran 75 mg daily -aldactone 100 mg daily -lasix 40 mg daily -prednisone 20 mg daily -solu-cortef 100 mg iv bid -vanc 1 g iv bid -garamycin 80 mg iv q 8hr since [**5-19**] -heparin gtt discharge medications: 1. albuterol sulfate 0.083 % solution sig: one (1) inhalation q4h (every 4 hours) as needed. 2. ciprofloxacin 0.3 % drops sig: one (1) drop ophthalmic q3h (every 3 hours): right eye. 3. brimonidine 0.15 % drops sig: one (1) drop ophthalmic [**hospital1 **] (2 times a day): right eye. 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) ml intravenous daily (daily) as needed. 6. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 7. miconazole nitrate 2 % powder sig: one (1) appl topical [**hospital1 **] (2 times a day). 8. ondansetron hcl (pf) 4 mg/2 ml solution sig: one (1) injection q8h (every 8 hours) as needed. 9. oxycodone-acetaminophen 5-325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 10. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 11. penicillin g potassium 5,000,000 unit recon soln sig: one (1) recon soln injection q4h (every 4 hours). 12. prednisolone acetate 1 % drops, suspension sig: one (1) drop ophthalmic q3h (every 3 hours): right eye. 13. senna 8.6 mg tablet sig: one (1) tablet po daily (daily) as needed. 14. timolol maleate 0.5 % drops sig: one (1) drop ophthalmic [**hospital1 **] (2 times a day): right eye. 15. citalopram 20 mg tablet sig: 0.5 tablet po daily (daily). 16. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 17. lactulose 10 g/15 ml syrup sig: forty five (45) ml po tid (3 times a day). 18. rifaximin 200 mg tablet sig: one (1) tablet po tid (3 times a day). 19. prednisone 20 mg tablet sig: one (1) tablet po daily (daily) for 2 days: please continue for [**6-13**] and [**2198-6-14**]. . 20. prednisone 10 mg tablet sig: one (1) tablet po once a day: please start on [**2198-6-15**] and continue indefinitely. . 21. insulin please continue glargine and humalog per sliding scale insulin sheet attached to discharge paperwork. discharge disposition: extended care facility: [**hospital1 700**] - [**location (un) 701**] discharge diagnosis: primary: endocarditis with mitral valve rupture endophtalmitis with irreversible loss of vision od septic emboli brain autoimmune hepatitis with cirrhosis and bilirubinemia secondary: diabetes mellitus anemia thrombocytopenia funguria vaginal bleeding urinary retention hepatic encephalopathy discharge condition: fair to good. discharge instructions: you were admitted with an infection in your heart (endocarditis), which has damaged one of your heart valves, the mitral valve. in addition, your right eye was severely infected with endophtalmitis and you also had some septic emboli to your brain. other problems with which you presented were uncontrolled blood sugars, anemia (low blood), and yeast infection to your urine. you were desensitized to penicillin and have been receiving penicillin intravenously. this antibiotic needs to be continued for at least 6 weeks, and can be administered through the picc line that was placed in your right arm. you need to follow the recommendations of your infectious disease doctor (with whom you have an appointment) as to the exact number of days you must take antibiotics. please continue the antibiotics until you see the id physician. [**name10 (nameis) 62007**] medical consults were ordered while you were in the hospital: - the liver service recommended you stop taking imuran. your steroid dose was also slowly reduced to 20 mg daily, which is your current dose and will be further tapered to 10 mg daily. - the eye doctors recommend surgery on your right eye, and you need to follow up with them. you must protect your left eye at all times. - you were also seen by a gynecologist for vaginal bleeding, and you need to arrange for an endometrial biopsy as an outpatient. - the gi doctors examined your [**name5 (ptitle) 62008**], stomach and duodenum and found enlarged veins. you were started on a medication to control your fluid status, lasix, once a day. you were also started on a new blood pressure medication, lisinopril. your nadolol dose was increased to help your heart. however due to lower blood pressures, these medications were stopped and can be restarted slowly. followup instructions: dr [**last name (stitle) **] (eye, [**last name (un) **] center) [**2198-6-22**], 2:30 pm with your gynecologist as soon as feasible. with provider (infectious disease): [**first name8 (namepattern2) 7618**] [**name8 (md) **], md phone:[**telephone/fax (1) 457**] date/time:[**2198-6-19**] 9:00 with provider: [**name10 (nameis) **] [**last name (namepattern4) 2424**], md phone:[**telephone/fax (1) 2422**] date/time:[**2198-9-6**] 10:45 [**first name11 (name pattern1) 734**] [**last name (namepattern1) 735**] md, [**md number(3) 799**]",0
77,"admission date: [**2147-6-16**] discharge date: [**2147-7-10**] date of birth: [**2090-12-26**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**last name (namepattern4) 290**] chief complaint: hypoxia major surgical or invasive procedure: placement of central line (r ij under ultrasound) placement of arterial lines history of present illness: hpi: 56 f with no sig pmh presented to [**hospital3 10310**] hospital in [**location (un) 14663**] after 6 day illness described as fever, cough, dyspnea, and poor appetite. in ed, fever to 104 hr 130s bp 121/33, rr 40 o2 88% ra. cxr at osh suggestive of multilobar pna. pt was given ceftriaxone and azithro in ed and admitted to floor. overnight, pt continued to be tachypnic rr 40s, difficult oxygenating. pt was tried on bipap overnight. despite this at 4 am, hr increased 150s, rr 60s. abg: 7.27/? pco2 /84 on 100% bipap. a decision was made to intubate patient. post intubation abg 7.26/43/78 on fio2 100% simv 600/14/1.0/5 in addition, overnight her wbc fell from 10--> 7 and patient developed bandemia to 41%. antibiotics broadened from ceftriaxone/ azithro to zosyn, levo, flagyl. no lactate in outside hospital records. blood pressure remained stable, but due to difficulty with ventilation, a decision was made to transfer patient to [**hospital **] hospital icu for swan. however, patient noted to be hypoxic on leaving hospital. her transfer paralyzed with vecuronium and re-routed to [**hospital1 18**] for further care. . on arrival, pt appeared ashen, diaphoretic. vs on arrival to [**hospital1 18**] were: t 102.7 hr 140s bp 150/60s rr 26 o2 94% on fio2 100% on ac 450/26/15/60 . immediately on arrival to [**hospital unit name 153**], a rij line was placed under ultrasound guidance with 1 stick and a left a-line was placed after many attempts. past medical history: smoking (? copd) abnormal [**last name (un) 3907**] -> bilateral calcifications s/p tubal ligation ""hoarse voice"" social history: etoh: 3 drinks/day; more on weekend tob: 1ppd x years works with stained glass. married. has two daughters. daughter [**name2 (ni) 23829**] is a pa at [**hospital 10596**]. family history: nc physical exam: vs: t 102.7 hr 140s bp 112/ 63 rr 26 o2 89% on ac 450/26/1.0/15 gen: middle aged f heavily sedated, initially not moving at all [**1-4**] paralysis, but increasing spontaneous movements to stimulation heent: pupils sl assymmetric r(2) > l(1), both minimally reactive. raises eyebrows to stimulus. neck: thick. no inc jvp visible lungs: coarse breath sounds throughout anteriorly. no wheezes. cv: tachycardic, regular. no m/r/g. abd: hypoactive bs. soft. sl distended. extr: edema. 2+ dp, radial pulse thready intermittently. neuro: heavily sedated. initially flacid. pertinent results: on admission [**2147-6-16**]: cxr: bilateral dense infiltrates l > r. r diaphragm still sharp. ? b/l pneumonia vs pulm edema vs ards. . head ct: osh negative for bleed; midline shift . chest ct: ([**2147-6-28**]) 1. no evidence of pulmonary embolism. 2. moderate bilateral pleural effusions, with compressive atelectasis. 3. multifocal areas of lung consolidation. . ekg: sinus tach 140s. no acute st segment changes . ruq u/s: impression: fatty infiltration of the liver. please note that more advanced liver disease and other types of liver disease, including cirrhosis/fibrosis, cannot be excluded by ultrasound in the presence of fatty infiltration. no evidence for cholecystitis. . osh labs: [**2147-6-15**]: 10.1/42.8/215 (89n, 8 b)and na 121 [**2147-6-16**]: 7.0/40.1/183 (49n, 41b) [**2147-6-16**]: 8.0/39.9/192; na 128, k 4.1, cl 95, c 22, bun 25, cre 1.3, gluc 136, ca 8/ mg 2.0/phos 4.0 amylase/lipase normal ast 157/ alt 91/ alk phos 120/ t bili 1.0/ alb: 2.8 . initial abg: 7.23/55/70; lactate 1.3 [**2147-7-10**] 04:06am blood wbc-10.3 rbc-3.83* hgb-12.3 hct-36.1 mcv-94 mch-32.1* mchc-34.0 rdw-14.1 plt ct-446* [**2147-7-10**] 04:06am blood glucose-83 urean-21* creat-1.1 na-138 k-3.4 cl-100 hco3-20* angap-21* [**2147-7-9**] 04:57am blood glucose-81 urean-24* creat-1.1 na-140 k-3.6 cl-102 hco3-23 angap-19 [**2147-7-9**] 04:57am blood alt-36 ast-38 ld(ldh)-298* alkphos-152* totbili-0.6 [**2147-6-16**] 07:45pm blood alt-91* ast-157* ck(cpk)-587* alkphos-120* amylase-35 totbili-1.0 [**2147-6-16**] 07:45pm blood lipase-12 [**2147-7-10**] 04:06am blood calcium-9.4 phos-4.6* mg-1.7 [**2147-6-17**] 09:40am blood tsh-0.95 [**2147-7-6**] 08:56am blood type-art temp-38.6 rates-/15 peep-5 fio2-40 po2-97 pco2-41 ph-7.45 calhco3-29 base xs-3 intubat-intubated vent-spontaneou [**2147-7-4**] 03:11am blood lactate-1.1 [**2147-7-5**] 06:21pm urine blood-lge nitrite-neg protein-30 glucose-neg ketone-50 bilirub-neg urobiln-neg ph-6.5 leuks-mod [**2147-7-5**] 06:21pm urine rbc->1000* wbc-48* bacteri-many yeast-none epi-<1 brief hospital course: a/p: 56 yo female transferred to [**hospital unit name 153**] from [**hospital3 10310**] hospital with severe bilateral pneumonia, now known to be legionella based on urinary ag from osh and respiratory culture findings. . 1. respiratory failure: pt was in ards on admission and hypoxemic. had been intubated at the osh but was difficult to ventilate and required paralytics to get her to breathe in sync with the ventilator. she was paralyzed with cisatrucurium for one day, then paralysis was lightened as the patient was able to work with the vent. she was kept on ceftriaxone and azithromycin for presumed community-acquired pneumonia until the urinary legionella ag from the osh came back positive. ceftriaxone was then discontinued, and the patient completed a 14 day course of azithromycin for legionella pneumonia. for sedation, she was on versed and fentanyl which both needed to be escalated to keep her sedated. after a week, she was switched over to propofol for better sedation and to prevent further escalation of fentanyl/versed. she was volume overloaded throughout the course of her ards due to acute renal failure requiring 3 days of hemodialysis. once the arf resolved, she began to mobilize fluids on her own and diurese. with diuresis, her oxygenation began to improve and she was able to tolerate extended trials of pressure support. she was given boluses of lasix, then a lasix gtt, to enhance her diuresis with the goal being extubation. she was extubated on [**2147-6-28**] and did well for the first twelve hours. however, at approximately 2am, her o2 sats began to drop on 4l nc and she became tachypneic with a rr in the 50s. she was placed on facemask, then a nrb to keep her sats in the 90s. a cxr was taken at the time and looked like she was in chf. her abg at the time was 7.41/45/152 so she was kept on 100% fm and given 40mg lasix iv. attempts were made at noninvasive interventions with further diuresis and a trial of bipap but the patient began to tire and she was reintubated to improve her respiratory status. ekg and cardiac enzymes were negative, excluding a cardiac cause for her decompensation. a ct scan was negative for pe, but did show moderate sized bilateral pleural effusions with compressive atelectasis. she also had thicker sputum, a fever, and an elevated white count, concerning for perhaps a vap. empiric antibiotic therapy was started (piptazo, levaquin, and vanco). once reintubated, her sedation was kept light and the patient was able to maintain her oxygenation on settings of ac 500x12, .4, and 10 of peep. she was very sensitive to the peep, leading us to believe that the etiology for her desaturation after extubation was decruitment of some critical number of her alveloi, causing atelectasis and an inability to maintain her oxygentation. she was given boluses of lasix to aid her diuresis, with the goal of being net negative 2l each day. the pt continued to have fevers and a urine culture showed probable enterococcus. ciprofloxacin 500mg [**hospital1 **] was started. sedation was decreased and the patient was extubated on the [**7-7**]. the patient tolerated the extubation well and did not have any further supplemental oxygen requirements. the patient remained afebrile and the course of ciprofloxacin was terminated after 5 days. would recommend that patient get a cxr as an outpatient following discharge to ensure that pneumonia has fully cleared. clinical exam on discharge suggests that pneumonia has resolved. . 2. acid base disorders: initially the patient was acidemic with a primary respiratory acidosis. she then developed an anion gap metabolic acidosis (felt to be due to lactate) and a nongap metabolic acidosis (due to fluid resuscitation and renal failure). she was put on a bicarb gtt to correct her acidosis with good effect on her ph, but due to volume overload, it could not be continued. her ph normalized with hemodialysis and then became alkalemic after her first extubation, likely due to a contraction alkalosis during diuresis. the alkalosis resolved after extubation. however, prior to discharge her labs were suggestive of a metabolic acidosis and alkalosis. this was thought to be related to the initiation of hydrochlorothiazide for blood pressure control. hctz was therefore stopped and it is recommended that patient's primary care physician address the best intervention for blood pressure control. . 3. tachycardia: she was tachycardic on presentation, but it resolved with treatment of her hypoxia. she was intermittently tachycardic throughout the hospital course, but usually only in the settings of agitation, fever or respiratory distress. . 4. bp management: she was hypotensive on admission and required levophed until [**6-20**]. she remained normotensive for the remainder of her hospital course, except for periods of acute agitation or respiratory distress when she would become acutely hypertensive. on admission, many attempts were made to place an a-line in either of her wrists, and eventually anesthesia was able to get a line access in her l radial artery. she had multiple ecchymoses from these attempts on both of her forearms. once her original a line was lost, she had an a line placed in her r dorsalis pedis artery and then her r radial artery. bp normalized without any further fluid therapy and the pt tolerated the diureses of 2-3l daily well. once extubated the patient developed hypertension and was started on hctz 12.5mg po daily. as mentioned above, this was stopped secondary to acid-base abnormalities and we recommend that hypertension be addressed on an outpatient basis. . 5. sodium balance: she was hyponatremic on admission with a na of 128, thought to be due to the legionella infection. it slowly resolved with fluid resuscitation, until she became hypernatremic and hyperchloremic. free water boluses were added to her tf to correct her hypernatremia, but were discontinued in light of her volume status. they were restarted after she became reintubated at 250ml q4 until her na came down to 145. sodium levels remained within normal levels with diureses and no free water boluses were required. . 6. leukocytosis: she had a leukocytosis on presentation, likely due to her pneumonia. it was also compounded by steroids as she failed her [**last name (un) 104**]-stim test and was treated with 7 days of hydrocortisone and florinef for adrenal insufficiency, (last day was [**6-24**]). the only microbiology culture which ever grew a positive result was her respiratory culture from [**6-16**] which grew gram negative rods, thought to be legionella. the final result is still pending as it was sent to the state lab. all other cultures results (stool, sputum, urine, and blood) were negative. antibiotics were started on her reintubation for empiric therapy of a vent-associated pneumonia. however, she developed a drug rash and a fever while on those abx (first piptazo, then cefepime), so all abx were discontinued as the probability of her having a vap causing her reintubation was very low. the patient continued to have fevers and a urine culture was positive for enterococcus. ciprofloxacin was given for five days. the fever resolved and the patient remained afebrile. . 7. arf: her cr was 1.3 on admission and peaked at 5.1. her renal failure was thought to be due to atn [**1-4**] hypotension while septic. while in arf, she was virtually anuric and became volume overloaded with increasking k, increasing ph, low ph, and difficulty making progress with the ventilator. she was initially unresponsive to lasix and thus a quenten catheter was placed in her r femoral artery for hemodialysis. she was on hd for three days and tolerated it very well without any episodes of hypotension. after hd, she began to make her own urine and appeared to be in post-atn diuresis. lasix was given, iv and as a gtt, to assist in diuresis with good effect. after her reintubation, she required a ct scan with contrast to r/o a pe and we attempted to protect her kidneys with bicarb ivf and mucomyst. her cr did not bump post-scan, and her urine output continued to be 1-2l per day. the cr came down to 0.9 and the patient was diuresing well. however, prior to discharge her cr was ranging from 1.1-1.2. her baseline is likely much lower and there is likely some element of renal dysfunction secondary to her prolonged illness and hospital course. it is recommended that her lab values be followed up as an outpatient. . 8. hyperglycemia: the patient was placed on an insulin gtt during the acute phase of her illness to maintain tight glycemic control while she was critically ill. she had no h/o dm, and as her illness resolved, she was able to be weaned to a riss with good results. fs were typically within 100s-140s. . 9. anemia: the patient had a macrocytic anemia on presentation. hemolysis labs were negative, b12 and folate were high. likely etiology is etoh-induced. our goal for mrs. [**known lastname 63809**] was to keep her hct above 24. she required two transfusions, one unit of prbc on [**6-21**] and one unit on [**6-29**]. she tolerated both transfusions well without any signs or symptoms of fever, chills, or adverse reactions. she did not require any further transfusions. anemia had improved on discharge. . 10. transaminitis: on admission, she had ast>alt and alk phos 120, felt to be due to etoh use. the ratio of her lfts then changed, with alt>ast and alk phos becoming even higher. the etiology of her transaminitis is unclear. [**name2 (ni) 3539**] is 0.4 and patient does not appear jaundiced, so likely not obstructive. on exam, she had no hepatosplenomegaly or abdominal pain. most likely cause was medication, as lfts continued to trend downward with the resolution of her illness and removal of many of her medications. a ruq ultrasound during her admission reveladed a fatty liver but no evidence of biliary pathology. lfts should be followed up on an outpatient basis to ensure that they continue to trend downward. . 11. neuro status: on presentation, mrs. [**known lastname 63809**] was unresponsive but on high doses of sedation, analgesia, and paralytics. when the medication was weaned down, her mental status did not improve, her pupils were asymmetric and sluggish, and she appeared to have upgoing toes bilaterally and hyperreflexia on the right. a ct of her head was done to assess for intracranial pathology and it was negative. her sedation was changed to propofol as she began to develop a tolerance to fentanyl and versed and required higher doses to achieve adequate sedation. once weaned to propofol, it seemed that her neuro status improved. she was able to follow commands and interact more appropriately. on extubation, she asked appropriate questions and was able to be oriented. she was awake, alert and appropriate. her family reports that she is not quite at her baseline mental status. we would recommend following this closely and evaluating further if she does not return to her baseline in the near future. . 12. fen: the patient had an ogt placed during her admission and received tube feeds at goal of 40cc/hr. had difficulty with diarrhea at start of illness, but stool cx for c diff were negative. the patient was switched to po intake after extubation and tolerated it well. given patient's significant etoh history the patient should be continued on thiamine and folate. . 13. code status: full code . 14. communication: with husband [**name (ni) **], daughter [**name (ni) 23829**] . medications on admission: aspirin for headache dristan cold medicine discharge medications: 1. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 2. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 3. lorazepam 1 mg tablet sig: 1-4 tablets po q4-6h (every 4 to 6 hours) as needed for anxiety. 4. ipratropium bromide 18 mcg/actuation aerosol sig: six (6) puff inhalation q4-6h (every 4 to 6 hours) as needed. discharge disposition: extended care facility: [**hospital **] medical center - [**hospital1 3597**] discharge diagnosis: pneumonia discharge condition: stable discharge instructions: please discharge patient to [**hospital **] medical center. followup instructions: please follow up with your pcp after leaving rehabilitation. your physician should check [**name initial (pre) **] chest xray and labs to make sure everything has returned to [**location 213**]. [**initials (namepattern4) **] [**last name (namepattern4) **] [**name8 (md) **] md [**md number(1) 292**] completed by:[**2147-7-10**]",1
78,"admission date: [**2183-9-23**] discharge date: [**2183-9-24**] date of birth: [**2119-11-18**] sex: f service: medicine allergies: penicillins / tetracycline / iv dye, iodine containing contrast media attending:[**first name3 (lf) 3565**] chief complaint: carboplatin desensitization major surgical or invasive procedure: none history of present illness: 63f with stage iiic poorly differentiated primary peritoneal carcinoma, now with disease recurrence and participating in a [**company 2860**] clinical trial. when she last received chemotherapy on [**2183-9-2**], a third of the way through the infusion of carboplatin, she developed an intense feeling of heat and generalized body tingling, tingling and numbness of the lips, and chest tightness. carboplatin was discontinued and she received 100 mg hydrocortisone and 50 mg of benadryl iv. her vital signs remained stable, but she later had vomiting and headache. given her allergic reaction, today she will receive paclitaxel followed by carboplatin per the desensitization protocol. on arrival to the micu, patient's vs were t 98.8, 90, 124/84, 19, 98%ra. patient appeared slightly anxious, but was in no respiraotry distress. past medical history: past oncologic history: - ct abd/pelvis on [**2182-2-28**] revealed a large mass centered in the sigmoid colon with pelvic lymphadenopathy, retroperitoneal lymphadenopathy, and peritoneal carcinomatosis. - a colonoscopy revealed a fungating, ulcerated mass within the sigmoid colon causing a partial obstruction. the biopsy of this mass revealed adenocarcinoma with papillary formation, suggestive of an ovarian primary. - [**2182-3-14**] underwent exploratory laparotomy, hysterectomy, bilateral salpingo-oophorectomy, rectosigmoid resection with colorectal re-anastomosis and diverting loop ileostomy. this was a suboptimal tumor debulking. intra-operatively, the uterus and bilateral adnexal were unremarkable. extensive firm retroperitoneal lymphadenopathy was appreciated. there was no evidence of carcinomatosis. the tumor was noted to involve the sigmoid colon and rectum. pathology examination revealed serous carcinoma involving full thickness of the rectal wall. seven of eight lymph nodes were positive for malignancy. uterus, cervix, fallopian tubes, and ovaries were negative for malignancy. - [**4-26**] start chemotherapy with carboplatin q21d and weekly taxol - [**2182-5-30**] cycle 3 carboplatin and taxol . other past medical history: - thalassemia. social history: imigrated from [**country 3587**] in youth. formerly employed in retail sales. no children, husband lives in [**country 3587**]. sister and [**name2 (ni) 802**] in [**name (ni) 86**] area. - tobacco: never - etoh: denies - illicits: denies family history: uncle: diabetes. mother and father lived in to 70's, she denies family history of cancer, cad, hypertension. physical exam: admission physical general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, grossly normal sensation discharge physical general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, grossly normal sensation pertinent results: [**2183-9-22**] 08:10am blood wbc-5.4 rbc-4.00* hgb-8.7* hct-27.5* mcv-69* mch-21.7* mchc-31.6 rdw-19.2* plt ct-213 [**2183-9-24**] 05:03am blood wbc-10.9# rbc-4.01* hgb-8.5* hct-27.3* mcv-68* mch-21.3* mchc-31.3 rdw-19.6* plt ct-200 [**2183-9-23**] 11:20am blood glucose-130* urean-23* creat-0.8 na-139 k-4.1 cl-107 hco3-25 angap-11 [**2183-9-24**] 05:03am blood glucose-158* urean-25* creat-0.9 na-140 k-4.2 cl-106 hco3-21* angap-17 [**2183-9-23**] 11:20am blood calcium-9.7 phos-2.8 mg-1.7 [**2183-9-24**] 05:03am blood calcium-9.1 phos-3.0 mg-2.1 brief hospital course: # carboplatin desensitization: patient was seen by dr. [**first name8 (namepattern2) 2602**] [**name (stitle) 2603**] from the department of allergy, who recommended that she receive carboplatin administered per the standard 12-step desensitization protocol. she also received taxol. pre-medication orders were entered by the pharmacist and co-signed by the [**name2 (ni) 153**] team. the patient is understandably anxious given that she had an adverse reaction to carboplatin previously. carboplatin desensitization was completed without incident. lfts were stable. patient was discharged home after discussion with oncology. # qtc monitoring: because of large doses of ondansetron, qtc prolongation was monitored. patient received electrolyte repletion and was monitored by serial ekg. qtc was 405 msec. patient was discharged home on hospital day 2. medications on admission: colace 100mg [**hospital1 **] prn constipation discharge medications: colace 100mg [**hospital1 **] prn constipation discharge disposition: home discharge diagnosis: primary: chemo desensitization secondary: primary peritoneal carcinoma discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. [**known lastname 47639**], it was a pleasure to take care of you at [**hospital1 18**]. you were admitted for a round of chemotherapy with carboplatin and paclitaxel. you were treated aggressively as per a desensitization protocol to prevent an allergic reaction. you tolerated the chemotherapy well and were discharged home. no changes were made to your home medications. please follow-up with you hematologist-oncologist's office as noted below. followup instructions: department: hematology/oncology when: monday [**2183-10-13**] at 11:00 am with: [**first name8 (namepattern2) **] [**last name (namepattern1) 3240**], rn [**telephone/fax (1) 22**] building: [**hospital6 29**] [**location (un) 24**] campus: east best parking: [**hospital ward name 23**] garage department: hematology/oncology when: monday [**2183-10-13**] at 11:00 am with: [**initials (namepattern4) **] [**last name (namepattern4) **], 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: hematology/oncology when: monday [**2183-10-13**] at 11:00 am with: [**name6 (md) 5145**] [**name8 (md) 5146**], md, phd [**telephone/fax (1) 22**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) 24**] campus: east best parking: [**hospital ward name 23**] garage completed by:[**2183-9-24**]",1
79,"admission date: [**2183-10-14**] discharge date: [**2183-10-15**] date of birth: [**2119-11-18**] sex: f service: medicine allergies: penicillins / tetracycline / iv dye, iodine containing contrast media attending:[**last name (namepattern4) 290**] chief complaint: carboplatin allergy coming in for desensitization major surgical or invasive procedure: none history of present illness: 63f with stage iiic poorly differentiated primary peritoneal carcinoma, now with disease recurrence and participating in a [**company 2860**] clinical trial. she is admitted to the icu for cycle 4 [**doctor last name **]/taxol therapy with carboplatin desensitization. when she last received chemotherapy on [**2183-9-2**], a third of the way through the infusion of carboplatin, she developed an intense feeling of heat and generalized body tingling, tingling and numbness of the lips, and chest tightness. carboplatin was discontinued and she received 100 mg hydrocortisone and 50 mg of benadryl iv. her vital signs remained stable, but she later had vomiting and headache. given her allergic reaction, she was admitted to the icu on [**9-23**] to receive carboplatin per the desensitization protocol. she tolerated the treatment without incident. today, she is directly admitted to the icu again for carboplatin desensitization. she denies any complaints, feels fine without pain, fever, nausea, vomiting, abdominal pain. on arrival to the micu, patient's vs. t 98.1, hr 90, bp 126/67, 94% on ra review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies shortness of breath, cough, or wheezing. denies chest pain, chest pressure, palpitations. denies constipation, abdominal pain, diarrhea, dark or bloody stools. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: - ct abd/pelvis on [**2182-2-28**] revealed a large mass centered in the sigmoid colon with pelvic lymphadenopathy, retroperitoneal lymphadenopathy, and peritoneal carcinomatosis. - a colonoscopy revealed a fungating, ulcerated mass within the sigmoid colon causing a partial obstruction. the biopsy of this mass revealed adenocarcinoma with papillary formation, suggestive of an ovarian primary. - [**2182-3-14**] underwent exploratory laparotomy, hysterectomy, bilateral salpingo-oophorectomy, rectosigmoid resection with colorectal re-anastomosis and diverting loop ileostomy. this was a suboptimal tumor debulking. intra-operatively, the uterus and bilateral adnexal were unremarkable. extensive firm retroperitoneal lymphadenopathy was appreciated. there was no evidence of carcinomatosis. the tumor was noted to involve the sigmoid colon and rectum. pathology examination revealed serous carcinoma involving full thickness of the rectal wall. seven of eight lymph nodes were positive for malignancy. uterus, cervix, fallopian tubes, and ovaries were negative for malignancy. - [**4-26**] start chemotherapy with carboplatin q21d and weekly taxol - [**2182-5-30**] cycle 3 carboplatin and taxol - thalassemia social history: imigrated from [**country 3587**] in youth. formerly employed in retail sales. no children, husband lives in [**country 3587**]. sister and [**name2 (ni) 802**] in [**name (ni) 86**] area. - tobacco: never - etoh: denies - illicits: denies family history: uncle: diabetes. mother and father lived in to 70's, she denies family history of cancer, cad, hypertension. physical exam: physical exam on admission: vitals: t 98.1, hr 90, bp 126/67, 94% on ra general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding, vertical midline scar gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. skin: right chest port in place discharge exam: vitals: t 98.4, bp 149/86, hr 82, rr 22, 99% on ra general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding, vertical midline scar gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. skin: right chest port in place pertinent results: admission labs: [**2183-10-14**] 01:45pm alt(sgpt)-41* ast(sgot)-27 alk phos-116* tot bili-0.3 discharge labs: [**2183-10-15**] 03:18am blood wbc-7.6 rbc-3.70* hgb-8.4* hct-25.8* mcv-70* mch-22.7* mchc-32.6 rdw-20.0* plt ct-214 [**2183-10-15**] 03:18am blood plt ct-214 [**2183-10-15**] 03:18am blood glucose-193* urean-24* creat-0.9 na-139 k-4.3 cl-105 hco3-24 angap-14 [**2183-10-15**] 03:18am blood alt-33 ast-25 alkphos-106* totbili-0.3 [**10-13**] ekg: normal sinus rhythm. tracing is within normal limits. compared to the previous tracing of [**2183-9-24**] there are no significant changes. micro: none imaging: none brief hospital course: brief hospital course: 63f with stage iiic poorly differentiated primary peritoneal carcinoma, now with disease recurrence and participating in a [**company 2860**] clinical trial admitted to icu for carboplatin desensitization. patient tolerated the treatment well without adverse effects. active issues: # carboplatin desensitization: patient has experienced feeling of heat, generalized body tingling, numbness of the lips, chest tightness,nausea, and headache with prior carboplatin infusion. she was last admitted to the icu in [**month (only) 216**] for carboplatin desensitization via protocol and tolerated in well. we followed the same protocol during this treatment course with premedication with diphenhydramine, famotidine, lorazepam and epinephrine and diphenhydramine prn ordered in event of reaction. the patient tolerated the treatment well and had no signs of hypersenstivity or adverse reaction. # stage iiic poorly differentiated primary peritoneal serous carcinoma: status post sub-optimal debulking surgery ([**2182-3-14**]) and 6 cycles ofchemotherapy ([**4-/2182**]/[**2182**]). five cycles with carboplatin and weekly taxol and 1 cycle with carboplatin and taxotere. ct torso on [**7-4**] documented disease recurrence. on [**8-11**] she started chemotherapy according to the clinical trial [**company 2860**] #11-228 (phase ii, multi-center, double-blind, placebo controlled, randomized study of ombrabulin in patients with platinum-sensitive recurrent ovarian cancer treated with carboplatin/paclitaxel). the second cycle was complicated by an allergic reaction to carboplatin and cycle 3 was administered without complication with desensitization protocol. the restaging ct torso performed on [**10-11**] showed stable disease with an overall increase in the tumor size of 17.8%. she was admitted to the icu for cylce 4 of carboplatin/paclitaxel with desensitization and tolerated it well without adverse reaction. she will follow up with her oncologist to schedule further chemotherapy treatments. she will need to be readmitted to the icu for future cycles for desensitization and monitoring. transitional care issues: 1. code status; full code 2. contact: brother in law [**name (ni) **] [**name (ni) **] 3. medication changes: none 4. follow up: with primary oncologist 5. pending studies: none medications on admission: zofran for nausea discharge medications: zofran for nausea discharge disposition: home discharge diagnosis: -stage iiic poorly differentiated primary peritoneal serous carcinoma -carboplatin desensitization discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: ms. [**first name8 (namepattern2) **] [**last name (titles) **], you were admitted to the hospital because you previously had allergic reactions to your chemotherapy, carboplatin. you were treated with a regimen to decrease your allergic reaction to this medication, which worked well, and you were discharged home. you will need this treatment prior to each of your future treatments with this medication. we have not made any changes to any of your medications. please continue to take them as previously prescribed. followup instructions: department: hematology/oncology when: monday [**2183-10-20**] at 8:45 am with: checkin hem onc cc9 [**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: monday [**2183-10-20**] at 9:30 am with: [**first name4 (namepattern1) 2747**] [**last name (namepattern1) 5780**], rn [**telephone/fax (1) 9644**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) 24**] campus: east best parking: [**hospital ward name 23**] garage [**initials (namepattern4) **] [**last name (namepattern4) **] [**name8 (md) **] md [**md number(1) 292**] completed by:[**2183-10-15**]",1
80,"admission date: [**2183-11-4**] discharge date: [**2183-11-5**] date of birth: [**2119-11-18**] sex: f service: medicine allergies: penicillins / tetracycline / iv dye, iodine containing contrast media attending:[**first name3 (lf) 338**] chief complaint: carboplatin desensitization major surgical or invasive procedure: none history of present illness: 63f with stage iiic poorly differentiated primary peritoneal serous carcinoma, now with disease recurrence and participating in a [**company 2860**] clinical trial, admitted to the icu for cycle 5 of [**doctor last name **]/taxol therapy with carboplatin desensitization. one third of the way through infusion of carboplatin during cycle 2 of chemotherapy on [**2183-9-2**], she developed an intense feeling of heat and generalized body tingling, numbness and tingling of the lips, and chest tightness. carboplatin was discontinued and she received 100 mg hydrocortisone and 50 mg of benadryl iv. her vital signs remained stable, but she later had vomiting and headache. given her allergic reaction, she was admitted to the icu to receive cycles 3 and 4 of carboplatin per the desensitization protocol. she has tolerated the treatments without incident. today, she is directly admitted to the icu again for carboplatin desensitization for cycle 5 of chemotherapy. on arrival to the micu, patient's vs: t 91, bp 122/71, hr 82, rr 19, spo2 93% ra. she denies any complaints, feels fine without pain, fever, nausea, vomiting, abdominal pain. review of systems: (+) per hpi (-) denies fever, chills, night sweats, headache, congestion, shortness of breath, cough, chest pain, palpitations, abdominal pain. past medical history: - stage iiic poorly differentiated primary peritoneal serous carcinoma - thalassemia - hypertension (per patient never treated with home medication, only when in hospital or seeing doctors) - gastritis/reflux oncologic history - ct abd/pelvis on [**2182-2-28**] revealed a large mass centered in the sigmoid colon with pelvic lymphadenopathy, retroperitoneal lymphadenopathy, and peritoneal carcinomatosis. - a colonoscopy revealed a fungating, ulcerated mass within the sigmoid colon causing a partial obstruction. the biopsy of this mass revealed adenocarcinoma with papillary formation, suggestive of an ovarian primary. - [**2182-3-14**] underwent exploratory laparotomy, hysterectomy, bilateral salpingo-oophorectomy, rectosigmoid resection with colorectal re anastomosis and diverting loop ileostomy. this was a suboptimal tumor debulking. intra-operatively, the uterus and bilateral adnexal were unremarkable. extensive firm retroperitoneal lymphadenopathy was appreciated. there was no evidence of carcinomatosis. the tumor was noted to involve the sigmoid colon and rectum. pathology examination revealed serous carcinoma involving full thickness of the rectal wall. seven of eight lymph nodes were positive for malignancy. uterus, cervix, fallopian tubes, and ovaries were negative for malignancy. - [**date range (3) 88205**]: 5 cycles of chemotherapy with carboplatin q21 days and weekly taxol, [**2182-8-15**] 6th cycle of chemotherapy with carboplatin and taxotere in place of taxol due to neurotoxicity - [**2183-7-12**]: mri of the l-spine shows new retroperitoneal lymphadenopathy consistent with disease recurrence. - [**2183-8-11**] started chemotherapy according to the clinical trial [**company 2860**] #11-228 (phase ii, multi-center, double-blind, placebo controlled, randomized study of ombrabulin in patients with platinum-sensitive recurrent ovarian cancer treated with carboplatin/paclitaxel) social history: immigrated from [**country 3587**] in youth. formerly employed in retail sales. no children, husband lives in [**country 3587**]. sister and [**name2 (ni) 802**] live in [**name (ni) 86**] area. - tobacco: never - etoh: denies - illicits: denies family history: mother and father lived to their 70s. family history of thalassemia. uncle with diabetes. she denies family history of cancer, cad, or hypertension. physical exam: admission physical exam: vitals: t 91, bp 122/71, hr 82, rr 19, spo2 93% ra general: nad, comfortable heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, no jvd appreciated, no ld cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound or guarding, epigastric hernia that is reducible, two large healed surgical scar from resection of cancer and cholecystectomy ext: warm, well perfused, 2+ pulses, 1+ edema up to knees neuro: cnii-xii intact, downgoing babinski discharge physical exam: vitals: t 98.4, bp 119/68, hr 80, rr 23, spo2 94% ra general: nad, comfortable heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, no jvd appreciated, no ld cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound or guarding, epigastric hernia that is reducible, two large healed surgical scar from resection of cancer and cholecystectomy ext: warm, well perfused, 2+ pulses, 1+ edema up to knees neuro: cnii-xii intact pertinent results: admission labs: [**2183-11-3**] 10:05am blood wbc-3.7*# rbc-3.84* hgb-8.9* hct-27.8* mcv-72* mch-23.1* mchc-32.0 rdw-20.1* plt ct-211 [**2183-11-3**] 10:05am blood neuts-48.9* lymphs-42.6* monos-7.1 eos-1.3 baso-0.2 [**2183-11-3**] 10:05am blood pt-11.2 inr(pt)-1.0 [**2183-11-3**] 10:05am blood urean-21* creat-0.8 na-143 k-3.6 cl-105 [**2183-11-3**] 10:05am blood glucose-182* [**2183-11-3**] 10:05am blood totprot-6.9 albumin-4.3 globuln-2.6 calcium-8.9 phos-3.8 mg-1.6 [**2183-11-3**] 10:05am blood alt-36 ast-32 alkphos-103 totbili-0.3 dirbili-0.1 indbili-0.2 [**2183-11-4**] 01:48pm blood alt-35 ast-29 ld(ldh)-267* alkphos-112* totbili-0.3 [**2183-11-3**] 10:05am blood ca125-40* discharge labs: [**2183-11-5**] 04:18am blood wbc-7.1# rbc-3.68* hgb-8.2* hct-26.1* mcv-71* mch-22.4* mchc-31.5 rdw-21.0* plt ct-202 [**2183-11-5**] 04:18am blood glucose-156* urean-23* creat-0.9 na-141 k-4.3 cl-105 hco3-24 angap-16 [**2183-11-5**] 04:18am blood alt-33 ast-29 alkphos-93 totbili-0.4 [**2183-11-5**] 04:18am blood calcium-9.2 phos-4.1 mg-1.7 studies: none micro: none brief hospital course: 63f with stage iiic poorly differentiated primary peritoneal serous carcinoma, now with disease recurrence and participating in a [**company 2860**] clinical trial, admitted to the icu for cycle 5 of [**doctor last name **]/taxol therapy with carboplatin desensitization. # carboplatin desensitization: cycle 2 was complicated by an allergic reaction after infusion of carboplatin which included a feeling of heat, generalized body tingling, numbness of the lips, chest tightness, nausea, and headache. patient was admitted to the icu for cycles 3 and 4 with carboplatin desensitization per protocol, and tolerated both cycles well. she underwent carboplatin desensitization per protocol for cycle 5 of [**doctor last name **]/taxol and tolerated well. at discharge, she was feeling well, able to eat and denied any pain, fevers, tingling. # stage iiic poorly differentiated primary peritoneal serous carcinoma: status post sub-optimal debulking surgery ([**2182-3-14**]) and 6 cycles of chemotherapy ([**4-/2182**]/[**2182**]); five cycles with carboplatin and weekly taxol and 1 cycle with carboplatin and taxotere. ct torso on [**7-24**] documented disease recurrence. on [**8-11**], she started chemotherapy according to the clinical trial [**company 2860**] #11-228 (phase ii, multi-center, double-blind, placebo controlled, randomized study of ombrabulin in patients with platinum-sensitive recurrent ovarian cancer treated with carboplatin/paclitaxel). the second cycle was complicated by an allergic reaction to carboplatin (see above), but cycles 3 and 4 were administered per the carboplatin desensitization protocol without complication. restaging ct torso performed on [**10-11**] showed no new lesions, but there is mild interval enlargement of right retroperitoneal lymph nodes and left external iliac chain lymph node which could reflect progression of metastatic disease. she completed cycle 5 of chemotherapy during this admission per [**company 2860**] clinical trial #11-228 and tolerated desensitization well (above). qtc was monitored while receiving high doses of ondansetron and remained within normal limits. # prophylaxis: heparin sq # communication: patient # code: full code # transitional issue: -patient has follow up with heme/onc on [**2183-11-11**] medications on admission: preadmission medications listed are correct and complete. information was obtained from webomr. 1. ondansetron 8 mg po bid:prn nausea 2. lorazepam 0.5 mg po q8h:prn anxiety 3. docusate sodium 100 mg po bid 4. senna 1 tab po bid:prn constipation discharge disposition: home discharge diagnosis: carboplatin desensitization discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. [**known lastname 47639**], it was a pleasure taking care of you during your hospitalization at [**hospital1 18**]. you were hospitalized to make sure that you did not have an adverse reaction while receiving your chemotherapy medications. you received your medications without any problems. please follow up with your cancer doctors. followup instructions: department: hematology/oncology when: tuesday [**2183-11-11**] at 8:45 am with: checkin hem onc cc9 [**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: tuesday [**2183-11-11**] at 9:30 am with: [**first name8 (namepattern2) 4617**] [**last name (namepattern1) 26978**], rn [**telephone/fax (1) 9644**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) 24**] campus: east best parking: [**hospital ward name 23**] garage department: hematology/oncology when: monday [**2183-11-24**] at 7:45 am with: checkin hem onc cc9 [**telephone/fax (1) 22**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) 24**] campus: east best parking: [**hospital ward name 23**] garage completed by:[**2183-11-5**]",0
81,"admission date: [**2167-8-13**] discharge date: [**2167-8-28**] date of birth: [**2125-2-9**] sex: m service: neurosurgery allergies: morphine attending:[**first name3 (lf) 5084**] chief complaint: refractory epilepsy major surgical or invasive procedure: [**2167-8-13**]: left craniotomy left temporal lobectomy history of present illness: mr [**known firstname **] [**known lastname 805**] is a 42yo gentleman who has been followed by dr. [**first name (stitle) **] as an epileptologist for several years now and also had a vns placed, which has not given him much relief of his seizures, which are located by several different convergent pieces of data including imaging and physiological eeg monitoring studies to be in the left temporal mesial area. he is a good candidate for a standard left temporal lobectomy, but he was worried previously about speech or language difficulties following surgery. he has progressed with his refractory seizure picture and has reached a point where he feels that it would be better for him to undergo the surgery at this point, especially with the lack of benefit from the vagus nerve stimulator. we talked about whether this would be left in or not. my recommendation would be to leave it in but turn it off following the surgery and leave it off until we can assess the overall outcome from the resective surgery itself. i went over the risks and benefits and details of this with him and we will plan a left temporal lobectomy with an amygdala hippocampectomy in the standard way past medical history: refractory temporal lobe epilepsy depression asthma kidney stones s/p t11-t12 and l5-s1 spinal fusion social history: divorced, lives alone, no tobacco/etoh/drugs. works as a speech & language therapist family history: there is no family history of epilepsy or febrile seizures. his paternal uncle has [**name (ni) 3832**] syndrome, his maternal grandfather had an mi at ages 50 and 70, his mother has breast cancer. physical exam: at time of discharge: moves lle/lue spontaneously, r hemiplegic, no spon movement rue/rle. no w/d to pain but has sensory in r side. speech improving, able to say name and answer simple questions with yes/no pertinent results: [**8-13**] nchct: status post left temporal lobectomy. hypodensity within the left inferior parietal and occipital lobes suggests edema; infarction cannot be excluded. [**8-13**] eeg:this is an abnormal continuous icu monitoring study because of the presence of slowing broadly present broadly over the left hemisphere and loss of fast frequency predominantly in the mid-posterior temporal region on the left. there were a few bursts of generalized slowing suggesting some deep midline compromise. no interictal or sustained epileptic activity was seen. [**8-13**] cta head: 1. hypodensity in the left occipital lobe with cutoff of the left posterior cerebral artery just distal to the p1 segment. these findings may reflect occlusion of the posterior cerebral artery with developing infarct in the occipital lobe. 2. expected postoperative changes status post left temporal lobectomy, with slightly increased hemorrhage within the surgical cavity. [**8-13**] mri brain: 1. acute infarct in the left occipital lobe and left thalamus as well as within the posterior limb of the internal capsule, corona radiata and insula. the extent of findings is less than on the ct; ct findings may therefore reflect a combination of edema and post-operative swelling. 2. expected postoperative findings of left temporal lobectomy, with hemorrhage within the operative bed. [**8-14**] ct head: 1. loss of [**doctor last name 352**]-white matter junction and hypodense left occipital lobe consistent with evolving, known left pca infarct. 2. new moderate to severe left cerebral edema with effacement of the left lateral ventricle and new midline shift to the right by 7 mm. [**8-14**] eeg: this is an abnormal continuous icu monitoring study because of asymmetric background with relative slowing over the left centro-temporal regions with loss of faster frequencies temporally suggestive of focal cortical dysfunction. there are intermittent bursts of generalized slowing suggestive of some deep midline compromise. no interictal or electrographic seizures are seen. mr head w/o contrast [**2167-8-18**] 1. interval enlargement of the large acute infarction in the left cerebral hemisphere, as detailed above, with increased mass effect and rightward shift of midline structures. 2. the temporal [**doctor last name 534**] of the right lateral ventricle has slightly increased in size, likely due to increased compression of the third ventricle, concerning for impending trapping. 3. small foci of hemorrhagic transformation in the left thalamus, and possibly also in the left occipital lobe. however, the left occipital hemorrhagic focus may be chronic. ct head w/o contrast [**2167-8-22**] 1. evolving left pca infarction with increased hypodensity involving parietal lobe, occipital lobe, and thalamus. mixed density in the left occipital lobe may represent hemorrhagic conversion. 2. stable shift of midline structures to the right, approximately 5 mm. quadrigeminal plate cistern remains patent bilat lower ext veins [**2167-8-22**] no evidence of dvt in either left or right lower extremity. brief hospital course: pt was electively admitted and underwent a left craniotomy and left temporal lobectomy. surgery was without complication. he was extubated and upon awakening was noted to be aphasic and to have right hemiplegia. he was taken for a stat head ct and then was transferred to the icu. ct was concerning for possible infarct so a stroke neurology consult was called. they recommended eeg, cta and mri. these were all performed. the patient was reintubated [**8-13**] pm due to poor neurological exam and airway protection. ce's remained negative. on [**8-14**] his r pupil was noted to be dilated to 8mm but still reactive. he was given a dose of decadron and it came down to 5mm while the left remained at 4mm. repeat head ct revealed l pca infarct, new l edema with mls & mass effect. family was updated. on [**8-15**], a swallow evaluation was ordered. on [**8-17**], patient expressed sucidial ideations and psych was consulted. they recommended increasing his zoloft dosing and add remeron qhs. swallow evaluation resulted in ""sips"" of small spoonfulls of nectar thick liquid as tolerated w/ 1:1 sitter. continue non-oral means of nutrition, meds and hydration. mri head was performed which confirmed l hemispheric infarct. on [**9-19**], no changes were seen in patient. he remained in icu awaiting a floor bed. on [**8-20**], patient was transferred to the floor. on [**8-21**], calorie counts were started to evaluate patient's food intake and necessity for peg. patient has low urine output and received 500cc bolus of ns. u/a was sent and was positive for uti, he was started on ceftriaxone. on [**8-22**], patient removed dophoff and attempts to replace were unsuccessful. while attempting to give pos, it was noted that patient was pocketing food and aspirating. chest x-ray was done which revealed atelectasis and question of new l retrocardiac opacity. patient was made npo and speech and swallow was reconsulted. on [**8-23**], patient continued to be agitated. on [**8-24**], patient reported abdominal pain in which gi was consulted for. he was started on emperic treatment for [**female first name (un) **], if no success, then he would need an egd. on [**8-25**], patient reported severe itching, he was prescribed benadryl and sarna lotion to help relieve these symptoms. dilaudid was also discontinued for fear of adverse reaction. lfts were ordered while patient on fluconazole. on [**8-26**] his diet was advanced. a family meeting was held and rehab placement was discussed. on [**8-27**] his affect was improved and more interactive. gabapentin was increased per neurology's recommendations. on [**8-28**] he was seen and examined and his speech was slightly improved. the neurology team also evalauted him and agreed that his exam has improved gradually. he was screened for rehab on [**8-28**] and was accepted to [**hospital1 **] in [**location (un) 86**]. the patient and family were in agreement with this plan and he was subsequently discharged to rehab in the afternoon of [**8-28**] with instructions for followup. all questions were answered regarding his plan of care prior to discharge. medications on admission: albuterol sulfate nr lacosamide [vimpat] vimpat levetiracetam lorazepam sertraline [zoloft] discharge medications: 1. acetaminophen 325-650 mg po q4h:prn pain, headache or fever 2. albuterol inhaler 2 puff ih q4h:prn wheeze, sob 3. artificial tear ointment 1 appl left eye prn dryness 4. bisacodyl 10 mg po/pr [**hospital1 **] constipation goal: [**12-1**] bm /day 5. cyclobenzaprine 10 mg po tid:prn back pain hold for sedation 6. clonazepam 0.5 mg po tid:prn seizrues 7. diazepam 5 mg po q6h:prn muscle spasm, anxiety 8. docusate sodium (liquid) 100 mg po bid 9. fluconazole 200 mg iv q24h duration: 10 days suspected esophageal candidiasis. total 14 day course started in hospital 10. gabapentin 600 mg po q8h 11. heparin 5000 unit sc tid 12. hydralazine 10-20 mg iv q4h:prn sbp>160mmhg 13. hydroxyzine 25 mg po q6h:prn pruritis 14. levetiracetam 1500 mg iv bid 15. milk of magnesia 30 ml po q6h:prn constipation 16. mirtazapine 30 mg po hs 17. multivitamins 1 tab po daily 18. nystatin ointment 1 appl tp qid:prn pruritis 19. ondansetron 4 mg iv q8h:prn n/v 20. oxycodone (immediate release) 5-10 mg po q4h:prn pain 21. pantoprazole 40 mg iv q12h 22. polyethylene glycol 17 g po daily 23. sarna lotion 1 appl tp qid:prn pruritis 24. sertraline 100 mg po daily 25. sucralfate 1 gm po tid administer as a slushy 26. sodium chloride 0.9% flush 3 ml iv q8h:prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. discharge disposition: extended care facility: [**hospital6 85**] - [**location (un) 86**] discharge diagnosis: refractory temporal lobe epilepsy dysphasia dysphagia hemiplegia esophagitis back pain depression discharge condition: mental status: confused - always. level of consciousness: lethargic but arousable. activity status: bedbound. discharge instructions: craniotomy for hemorrhage ?????? 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. ?????? your wound was closed with sutures. your staples have been removed and you may wash your hair now that they have been removed ?????? increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. we generally recommend taking an over the counter stool softener, such as docusate (colace) while taking narcotic pain medication. ?????? unless directed by your doctor, do not take any anti-inflammatory medicines such as motrin, aspirin, advil, and ibuprofen etc. ?????? you have been 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. followup instructions: follow-up appointment instructions ??????please call ([**telephone/fax (1) 88**] to schedule an appointment with dr. [**last name (stitle) **], to be seen in 4 weeks. ??????you will need a ct scan of the brain without contrast. completed by:[**2167-8-28**]",
82,"admission date: [**2198-11-28**] discharge date: [**2198-12-31**] date of birth: [**2145-9-4**] sex: f service: surgery allergies: no known allergies / adverse drug reactions attending:[**first name3 (lf) 6088**] chief complaint: poor wound healing, left lower extremity ischemia major surgical or invasive procedure: [**2198-12-6**]: 1. bilateral groin cutdowns. 2. left-to-right femoral-femoral artery bypass graft placement. 3. left femoral artery-to-above-knee popliteal artery bypass graft with non-reversed saphenous vein graft. [**date range (3) 88240**]: 1. exploration of left-to-right femoral-femoral artery bypass graft and left femoral-to-above-knee popliteal artery bypass graft. 2. [**doctor last name **] thrombectomy of femoral artery-to-femoral artery bypass graft and left femoral artery-to-above-knee popliteal artery bypass graft and [**doctor last name **] embolectomy of left aortofemoral bypass graft. 3. bovine patch angioplasty of proximal anastomosis of left femoral-to-above-knee popliteal artery bypass graft and vein patch repair of femoral-popliteal bypass. 4. aortogram. 5. selective catheterization of the femoral artery-to- femoral artery bypass graft and of the left femoral-to- above-knee popliteal bypass graft. 6. serial arteriogram of the left lower extremity. [**2198-12-20**]: left groin irrigation and debridement with sartorius muscle flap coverage of the vascular anastomosis and vacuum assisted dressing closure. history of present illness: 53 y/o f pmhx iddm, extensive vascular disease, and poor wound healing was a transfer from [**state **] center with concern for b/l foot osteomyelitis. she has a prior history of a chronic l foot ulcer s/p i&[**initials (namepattern4) **] [**last name (namepattern4) **] [**2197**] post with 6 week course of linezolide; r 2nd toe amputation [**2198-10-29**] for wet gangrene. 4 days prior to admission, vna noted increased erythema surrounding l foot ulcer after the pt wore wet shoes the day prior. denies any addition s/sx including: discharge, f/c, cough, sob/cp, n/v/d, abd pain, n/t/w (decreased b/l foot sensation at baseline), ha, or pain located over l or r foot ulcers, gi/gu frequency. continues to ambulate with cane. no exacerbating or relieving factors. identical to prior wound infections. . whilst at [**hospital **] hospital, pt started on vanco, evaluated by dr. [**last name (stitle) **], and had mri that showed questionable osteomyelitis; vanco changed to daptomycin for unclear reason upon chart review or questioning pt; no noted adverse reactions to vancomycin. pt transfer to [**hospital1 18**] for podiatry and vascular eval. in addition, inr noted to be > 3 and coumadin was held on admission. past medical history: type 2 diabetes mellitus copd/asthma atrial fibrillation chronic on coumadin hyperlipidemia mdd chronic anemia osteomyelitis - l foot s/p i&[**initials (namepattern4) **] [**2198-5-22**] peripheral vascular disease s/p amputation of r 2nd toe [**2198-10-29**] [**1-23**]; l abi 0.79, r 0.45 mediastinal adenopathy charcot feet deformity social history: disabled, history of remote tobacco use (20pyh). denies drug, and alcohol use lives with grandson; able to do adl's independently family history: brother, sister, father with dm physical exam: vs: t 97.7 bp 142/82 hr 50 sao2 98%ra general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: regular rate and rhythm, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, dopplerable dp pulses b/l skin: l foot: 1cmx4cm linear stage 3 ulcer along arch with marked area of erythema, no discharge, 1cm round stage 2 ulcer over 1st metatarsal; r foot: 2nd toe amputated with 1cm round stage 2 ulcer, and 1st metatarsal with 1cm round stage 2 ulcer; l groin with wound vac pulses: dopplerable dp/pt bilat neuro: cn 2-12 grossly intact; sensation below motor: 5/5 strength through ue/le bil sensation: decreased 2pt and proprioception at toes bil dtr: wnl pertinent results: [**2198-12-24**] 06:47am blood wbc-10.5 rbc-3.64* hgb-10.1* hct-30.6* mcv-84 mch-27.7 mchc-32.9 rdw-16.7* plt ct-587* [**2198-12-25**] 05:08am blood wbc-9.2 rbc-3.46* hgb-10.0* hct-29.0* mcv-84 mch-28.8 mchc-34.3 rdw-16.5* plt ct-596* [**2198-12-26**] 05:20am blood wbc-8.9 rbc-3.50* hgb-9.7* hct-29.5* mcv-84 mch-27.8 mchc-33.0 rdw-15.7* plt ct-565* [**2198-12-25**] 05:08am blood pt-21.2* ptt-28.9 inr(pt)-2.0* [**2198-12-26**] 05:20am blood pt-23.3* ptt-28.4 inr(pt)-2.2* [**2198-12-27**] 05:32am blood pt-24.1* inr(pt)-2.3* [**2198-12-28**] 06:02am blood pt-21.7* inr(pt)-2.0* [**2198-12-20**] 11:39am blood glucose-154* urean-28* creat-1.0 na-133 k-3.8 cl-97 hco3-29 angap-11 [**2198-12-21**] 05:00am blood glucose-55* urean-28* creat-1.1 na-133 k-3.9 cl-97 hco3-31 angap-9 [**2198-12-22**] 05:24am blood glucose-110* urean-32* creat-1.3* na-131* k-4.2 cl-96 hco3-30 angap-9 [**2198-12-23**] 05:36am blood glucose-148* urean-34* creat-1.3* na-132* k-3.8 cl-93* hco3-32 angap-11 [**2198-12-24**] 06:47am blood glucose-106* urean-33* creat-1.2* na-130* k-3.9 cl-95* hco3-29 angap-10 [**2198-12-25**] 05:08am blood glucose-138* urean-32* creat-1.1 na-133 k-3.8 cl-97 hco3-28 angap-12 [**2198-12-26**] 05:20am blood glucose-106* urean-31* creat-1.1 na-136 k-4.3 cl-101 hco3-31 angap-8 [**2198-12-24**] 06:47am blood calcium-9.0 phos-3.9 mg-2.0 [**2198-12-25**] 05:08am blood calcium-8.4 phos-3.1 mg-1.8 [**2198-12-26**] 05:20am blood calcium-9.1 phos-3.1 mg-1.9 [**2198-12-5**] 06:35am blood %hba1c-11.0* eag-269* [**2198-12-5**] 06:35am blood triglyc-95 hdl-44 chol/hd-2.4 ldlcalc-42 [**2198-12-3**] 09:39am blood tsh-0.090* [**2198-12-7**] 01:10pm blood tsh-0.16* [**2198-12-10**] 04:11am blood tsh-0.20* [**2198-12-12**] 04:45am blood tsh-0.14* [**2198-12-17**] 05:56am blood tsh-0.074* [**2198-12-24**] 06:47am blood tsh-0.088* [**2198-12-28**] 06:02am blood tsh-pnd [**2198-12-4**] 06:45am blood t4-6.5 t3-98 calctbg-0.86 tuptake-1.16 t4index-7.5 free t4-1.2 [**2198-12-7**] 01:10pm blood t4-5.2 t3-91 calctbg-0.88 tuptake-1.14 t4index-5.9 [**2198-12-10**] 04:11am blood t4-5.8 t3-76* calctbg-0.82 tuptake-1.22 t4index-7.1 [**2198-12-24**] 06:47am blood t4-10.2 t3-117 calctbg-0.82 tuptake-1.22 t4index-12.4* [**2198-12-24**] 06:47am blood crp-67.2* [**2198-12-20**] 10:00 am swab left groin. **final report [**2198-12-27**]** gram stain (final [**2198-12-20**]): no polymorphonuclear leukocytes seen. no microorganisms seen. wound culture (final [**2198-12-27**]): due to mixed bacterial types (>=3) an abbreviated workup is performed; p.aeruginosa, s.aureus and beta strep. are reported if present. susceptibility will be performed on p.aeruginosa and s.aureus if sparse growth or greater.. dr. [**last name (stitle) 10000**] requested further work-up [**2198-12-25**]. pseudomonas aeruginosa. sparse growth. escherichia coli. sparse growth. piperacillin/tazobactam sensitivity testing available on request. escherichia coli. rare growth. 2nd morphology. piperacillin/tazobactam sensitivity testing available on request. escherichia coli. rare growth. 3rd morphology. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | escherichia coli | | escherichia coli | | | escherichia coli | | | | amikacin-------------- 16 s ampicillin------------ =>32 r =>32 r =>32 r ampicillin/sulbactam-- =>32 r 16 i 16 i cefazolin------------- 8 s <=4 s <=4 s cefepime-------------- 8 s <=1 s <=1 s <=1 s ceftazidime----------- 4 s <=1 s <=1 s <=1 s ceftriaxone----------- <=1 s <=1 s <=1 s ciprofloxacin--------- =>4 r =>4 r =>4 r =>4 r gentamicin------------ =>16 r <=1 s <=1 s <=1 s meropenem------------- 8 i <=0.25 s <=0.25 s <=0.25 s piperacillin/tazo----- 16 s tobramycin------------ =>16 r <=1 s <=1 s <=1 s trimethoprim/sulfa---- =>16 r =>16 r =>16 r anaerobic culture (final [**2198-12-24**]): no anaerobes isolated. [**2198-12-11**] 5:22 am blood culture source: line-cvl. **final report [**2198-12-17**]** blood culture, routine (final [**2198-12-17**]): no growth. [**2198-12-8**] 3:41 pm swab source: rectal swab. **final report [**2198-12-11**]** r/o vancomycin resistant enterococcus (final [**2198-12-11**]): no vre isolated [**2198-12-3**] 7:58 am swab source: left foot. **final report [**2198-12-13**]** gram stain (final [**2198-12-3**]): no polymorphonuclear leukocytes seen. no microorganisms seen. wound culture (final [**2198-12-12**]): beta streptococcus group b. sparse growth. susceptibility testing requested by dr. [**last name (stitle) 59051**] #[**numeric identifier 88241**] [**2198-12-10**]. sensitivity testing performed by sensititre. this isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . staphylococcus, coagulase negative. rare growth. susceptibility testing requested by dr. [**last name (stitle) 59051**] #[**numeric identifier 88241**] [**2198-12-10**]. coag neg staph does not require contact precautions, regardless of resistance oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. sensitivities: mic expressed in mcg/ml _________________________________________________________ beta streptococcus group b | staphylococcus, coagulase negative | | clindamycin----------- r <=0.25 s erythromycin---------- =>4 r <=0.25 s gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r penicillin g----------<=0.06 s rifampin-------------- <=0.5 s tetracycline---------- <=1 s vancomycin------------ <=1 s <=0.5 s anaerobic culture (final [**2198-12-7**]): no anaerobes isolated. discharge labs: 140 105 31 50 agap=11 ------------- 4.4 28 0.8 estgfr: 75 / >75 (click for details) ca: 9.0 mg: 1.7 p: 3.6 pt: 18.6 ptt: 25.7 inr: 1.7 brief hospital course: 53yo f pmhx iddm, extensive vascular disease, and poor wound healing presenting with s/sx concerning for osteomyelitis and cellulitis of l foot ulcers. she was admitted to the medicine service for management of her osteomyelitis, foot ulcers, and multiple comorbidities, and was followed by podiatry bilateral charcot deformities. vascular surgery was consulted for concern for inadequate vascularization and further work-up revealed occlusion of her previous aorto-bifem graft. at that point, she was transferred to the vascular surgery service for further management. she was taken to the or for left-to-right fem-fem bypass and left femoral to above-knee popliteal artery bypass. this was complicated by graft thrombosis requiring take-back to the or the same night for thrombectomy. she required massive fluid resuscitation during the perioperative period, which caused respiratory and cardiac difficulties. neuro: her pain was well-controlled with oral and iv pain medications. she was intubated briefly in the post-operative period, sedated on fentanyl and versed, but responded appropriately when sedation was lightened. after extubation, she awoke and was alert and oriented, without neurologic deficits and no neurologic issues for the rest of her hospitalization. cv: she has chronic atrial fibrillation, which was well-controlled on her home medications until her massive fluid resuscitation. at that time, she went into afib with rvr, which required esmolol and diltiazem drips while in the icu for heart rate control. once her volume status improved, she was re-started on her home medications with good rate control and had no further issues during the course of her hospitalization. pulm: she has copd at baseline, which is well-controlled with inhalers. she was intubated for the or and could not be extubated until pod 3 due to her volume status. she had acute pulmonary edema and was heavily diuresed with lasix. once extubated she required intermittent bipap for a few days, and was then weaned to nasal cannula. her oxygen requirements continued to decrease as her volume status improved, until she was not requiring supplemental oxygen for the majority of her hospitalization. fen/gi: she required massive fluid resuscitation in the perioperative period, and was nearly 20 liters positive post-operatively. once her atrial fibrillation was controlled and her blood pressure stable, she was gently diuresed with a lasix drip. her electrolytes were monitored and repleted appropriately, and her kidney function remained stable. she received tube feeds for several days post-op, and began eating her regular diet once extubated. nutrition was consulted and provided recommendations to optimize intake to improve wound healing. dr. [**first name (stitle) 3209**] from podiatry recommended midfoot/forefoot reconstruction at a further date as an oupatient for charcot's foot. she should call the [**hospital1 18**] podiatric surgery clinic for further follow-up of this condition at ([**telephone/fax (1) 21608**]. gu: her kidney function was monitored regularily and remained stable. heme/id: she was admitted for management of left foot ulceration, cellulitis, and osteomyelitis. her x-rays on admission were concerning for osteomyelitis, and wound cultures grew group b strep and mrse. she was treated with vanco/cipro/flagyl. she was kept on a heparin drip for a-fib perioperatively, and then transitioned back to coumadin. picc was placed on [**12-18**] for long term abx and temporary central line removed. she was given 1 unit of rbcs on [**12-20**] for hct of 28, post transfusion hct showed no response. wound cultures from the or on [**12-20**] grew out multi drug resistant pseudomonas aeruginosa and 3 morphologies of e.coli. infectious disease was consulted and recommended cefepime 2 gm [**hospital1 **] and metronidazole 500 mg po tid. with duration of therapy 6 weeks following last debridement. she should have weekly cbc/diff, bun/cr, and lft's while on the above therapy; please have labs faxed per the opat note to id rn's at [**telephone/fax (1) 1419**]. endo: she has poorly controlled type 2 diabetes. we consulted endocrinology for recommendations for blood sugar control while admitted. a pre-op chest x-ray also revealed a large substernal thyroid mass causing tracheal deviation. endocrinology also evaluated her for this process and recommended outpatient biopsy with likely removal by thoracic surgery. she was continued on methimazole and tfts monitored throughout her hospitalization. endocrinology has recommended that she follow up with her outpatient endocrinologists in [**1-25**] weeks after discharge with a repeat of her thyroid function tests (tfts). left lower extremity wounds: she had left groin wound dehiscence and large amounts of serous drainage postoperatively. on [**12-20**], she was taken to the operating room for left groin wound debridement, sartorius flap, and vac placement. her vac was changed every three days while in the hospital. her left and right foot ulcers were debrided and treated with santyl ointment which should continue at discharge. at the time of discharge she was stable. her inr was 1.7 and she was continued on coumadin 5mg qhs. the vac was removed from her left groin wound and it was packed with wet to dry dressing. the vac should be replaced at the rehab facility. she will continue antibioitcs as indicated and follow up with the [**hospital **] clinic, the podiatry clinic and the vascular surgery clinic. medications on admission: omeprazole 40mg po daily imdur 30mg po qday hydralazine 10 po tid metoprolol 100mg po bid lipitor 20mg po qday lexapro 10mg po qday combivent 2 puffs qid prn ventolin hfa 2 puffs q4hrs prn mvit qday ferrous sulfate 325mg po qday coumadin 5mg qday lantus 80u subq daily humalog ss cardizem 240mg po qday discharge medications: 1. ceftazidime 2 gram recon soln sig: two (2) grams injection q8h (every 8 hours) for 6 weeks: start date [**2198-12-24**] for 6 weeks. stop date [**2199-2-4**]. disp:*qs * refills:*0* 2. heparin, porcine (pf) 10 unit/ml syringe sig: 2 ml mls intravenous prn (as needed) as needed for line flush: picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. . 3. metronidazole 500 mg tablet sig: one (1) tablet po q8h (every 8 hours): start date [**2198-12-24**] cont for 6 weeks stop date [**2199-2-4**]. 4. collagenase clostridium hist. 250 unit/g ointment sig: one (1) appl topical daily (daily). 5. bisacodyl 10 mg suppository sig: one (1) suppository rectal [**hospital1 **] (2 times a day) as needed for constipation. 6. diltiazem hcl 120 mg capsule, sustained release sig: two (2) capsule, sustained release po daily (daily). 7. escitalopram 10 mg tablet sig: one (1) tablet po daily (daily). 8. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day). 9. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 10. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 11. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 12. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for dyspnea. 13. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 14. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 15. ipratropium-albuterol 18-103 mcg/actuation aerosol sig: [**12-23**] puffs inhalation q6h (every 6 hours) as needed for sob, wheeze. 16. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation q4h (every 4 hours) as needed for sob, wheeze. 17. methimazole 10 mg tablet sig: three (3) tablet po daily (daily). 18. morphine 5 mg/ml solution sig: 2 mg iv injection before vac removal/placement (). 19. insulin glargine 100 unit/ml solution sig: 52 units subcutaneous at breakfast. 20. insulin sliding scale-humalog insulin sc sliding scale breakfast lunch dinner bedtime 71-119 10units 6units 9units 0units 120-140 12units 8units 11units 0units 141-199 14units 10units 13units 2units 200-239 16units 12units 15units 4units 240-280 18units 14units 17units 6units > 280 notify md 21. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm: please check inr twice per week; inr goal 2.0-3.0. 22. outpatient [**name (ni) **] work pt/inr labs twice weekly; please adjust coumadin dose as needed. inr goal 2.0-3.0 weekly cbc/diff, bun/cr, and lft's while on the antibiotics; please have labs faxed id rn's at [**telephone/fax (1) 1419**]. discharge disposition: extended care facility: [**hospital1 2670**] - the elms [**first name5 (namepattern1) 5871**] [**last name (namepattern1) **] discharge diagnosis: left lower extremity ischemia left groin lymphatic leak with wound dehiscence discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted for a lower extremity bypass operation that included establishing blood flow from your left femoral to right femoral artery and from your left femoral to left popliteal artery followed by an operation to protect your graft after lymphatic leak. you were also being treated with iv antibiotics to treat infection in the wounds. what to expect when you go home: 1. it is normal to feel tired, this will last for 4-6 weeks ?????? you should get up out of bed every day and gradually increase your activity each day ?????? unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? increase your activities as you can tolerate- do not do too much right away! 2. it is normal to have swelling of the leg you were operated on: ?????? elevate your leg above the level of your heart (use [**1-24**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? avoid prolonged periods of standing or sitting without your legs elevated 3. it is normal to have a decreased appetite, your appetite will return with time ?????? you will probably lose your taste for food and lose some weight ?????? eat small frequent meals ?????? it is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? to avoid constipation: eat a high fiber diet and use stool softener while taking pain medication what activities you can and cannot do: ?????? no driving until post-op visit and you are no longer taking pain medications ?????? unless you were told not to bear any weight on operative foot: ?????? you should get up every day, get dressed and walk ?????? you should gradually increase your activity ?????? you may up and down stairs, go outside and/or ride in a car ?????? increase your activities as you can tolerate- do not do too much right away! ?????? no heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? you may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? take all the medications you were taking before surgery, unless otherwise directed ?????? take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? call and schedule an appointment to be seen in 2 weeks for staple/suture removal what to report to office: ?????? redness that extends away from your incision ?????? a sudden increase in pain that is not controlled with pain medication ?????? a sudden change in the ability to move or use your leg or the ability to feel your leg ?????? temperature greater than 100.5f for 24 hours ?????? bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions open wound: vac dressing patient's discharge instructions introduction: this will provide helpful information in caring for your wound. if you have any questions or concerns please talk with your doctor or nurse. you have an open wound, as opposed to a closed (sutured or stapled) wound. the skin over the wound is left open so the deep tissues may heal before the skin is allowed to heal. premature closure or healing of the skin can result in infection. your wound was left open to allow new tissue growth within the wound itself. the wound is covered with a vac dressing. this will be changed around every three days. the vac helps keep the wound tissue clean, absorbs drainage, prevents premature healing of skin, and promotes appropriate healing. when to call the doctor: watch for the following signs and symptoms and notify your doctor if these occur: temperature over 101.5 f or chills foul-smelling drainage or fluid from the wound increased redness or swelling of the wound or skin around it increasing tenderness or pain in or around the wound followup instructions: your vascular surgery followup appointment: provider: [**name10 (nameis) 251**] [**last name (namepattern4) 1490**], md phone:[**telephone/fax (1) 1237**] date/time:[**2199-1-9**] 2:45 your infectious disease followup appointment: provider: [**name10 (nameis) **],[**name11 (nameis) **] [**name12 (nameis) **] id west (sb) phone:[**telephone/fax (1) 457**] date/time:[**2199-1-14**] 10:50 provider: [**first name8 (namepattern2) **] [**last name (namepattern1) 10000**], md phone:[**telephone/fax (1) 457**] date/time:[**2199-2-7**] 10:30 call podiatry for f/u completed by:[**2198-12-31**]",0
83,"admission date: [**2172-12-20**] discharge date: [**2172-12-23**] date of birth: [**2107-8-3**] sex: f service: medicine allergies: rituximab / vincristine / penicillins attending:[**first name3 (lf) 2485**] chief complaint: rituximab desensitization. major surgical or invasive procedure: blood transfusion, platelet transfusion history of present illness: for complete h&p please see initial bmt note. briefly this is a 65 y.o. female w/ refractory follicular lymphoma who recently established care w/ dr. [**first name (stitle) **] and dr. [**first name (stitle) **]. given the level of thrombocytopenia her treatment regimen is limited to rituximab. pt has history of complement mediated anaphylaxis reaction to rituximab hence the elective admission for desensitization. she was admitted to the icu for closer observation whilst undergoing desensitization. she has had 3 reactions to rituximab in the past. specifically she received her first dose in [**2168**] and she was noted to have chills, htn, rigors, sense of doom within an hour of infusion which was relived when the infusion was stopped. she underwent a retrial of rituximab in [**2170**] with a slower rate of infusion, unfortunately she had the sensation of throat tightening and itching and the infusion was stopped. she underwent another retrial several weeks ago with pretreatment of steroids, benadryl and unfortunately she was noted to have rigors, chills, htn, throat itching and ?swelling within an hour of infusion. per allergy their consensus is this is a complement mediated reaction and they recommend 48hours of iv methylprednisolone 40mg iv q6hours. on review of his history it appears he also has had significant fatigue over the past few weeks that was attributed to her pancytopenia. past medical history: oncology history: diagnosed at 65 y.o. with follicular lymphoma in [**2168**] during work up of boop. bm bx showed 40-50% celluarity, of which approximately 50% was lymphoma. she was started on r-chop but given her aforementioned reactions she received 6 cycles of chop, completing in [**2170-2-22**] and achieving a complete remission as documented by pet-ct on [**2170-4-13**]. she relapsed by ct scan in [**2171-2-23**] and received one cycle of fludarabine 50mg daily on days [**12-29**]. this treatment was complicated by febrile neutropenia and was discontinued. she then underwent six cycles of cvp, complicated by neuropathy. she achieved a partial remission based on ct in [**2171-6-25**], with a stable scan in [**2171-10-26**], [**2172-4-24**], and [**2172-9-24**]. she underwent a bone marrow bx on [**10/2172**] given persistent thrombocytopenia. bm bx showed increased celluarity with 70% of cellular material lymphoma cells consistent with her follicular lymphoma. she was started on chlorambucil 4mg daily on approximately [**2172-11-13**] which was complicated by leukopenia and admission for anemia two weeks later. follicular lymphoma (diagnosed [**2168**]-refractory) bronchiolitis obliterans organizing pneumonia social history: the patient has three sons and three grandchildren. she is a former sales clerk for an electronics company and now enjoys cooking in her free time. she does not drive due to peripheral neuropathy. she is a former light smoker and quit 6 years ago. she denies alcohol use. family history: nc physical exam: general: pleasant, well appearing caucasian female walking to bed from wheelchair in nad heent: no scleral icterus. perrl/eomi. mmm. cardiac: regular rhythm, normal rate. normal s1, s2. iii/vi sem noted in upper rt sternal border. 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. neuro: a&ox3. appropriate. cn ii-[**last name (lf) 7060**], [**first name3 (lf) 81**], xii intact. peripheral neuropathy noted b/l le to level of knee, b/l fingertips. 5/5 strength throughout. normal gait. pertinent results: [**2172-12-23**] 05:24am blood wbc-4.3 rbc-2.63* hgb-7.9* hct-22.3* mcv-85 mch-29.9 mchc-35.2* rdw-14.0 plt ct-36* [**2172-12-22**] 07:00am blood wbc-5.3# rbc-2.81* hgb-8.4* hct-23.3* mcv-83 mch-29.9 mchc-35.9* rdw-13.7 plt ct-42* [**2172-12-21**] 06:05am blood wbc-3.4*# rbc-2.87* hgb-8.5* hct-23.6* mcv-82 mch-29.6 mchc-36.1* rdw-13.6 plt ct-42* [**2172-12-20**] 10:30am blood wbc-1.7* rbc-2.38* hgb-7.1* hct-19.7* mcv-83 mch-30.1 mchc-36.3* rdw-14.2 plt ct-25* [**2172-12-23**] 05:24am blood neuts-90.4* lymphs-6.3* monos-3.1 eos-0.2 baso-0 [**2172-12-22**] 07:00am blood neuts-71.8* lymphs-23.8 monos-4.3 eos-0.1 baso-0 [**2172-12-20**] 10:30am blood neuts-20* bands-4 lymphs-48* monos-16* eos-4 baso-0 atyps-4* metas-4* myelos-0 [**2172-12-23**] 05:24am blood plt ct-36* [**2172-12-22**] 07:00am blood plt ct-42* [**2172-12-21**] 06:05am blood plt ct-42* [**2172-12-20**] 04:28pm blood plt ct-41*# [**2172-12-20**] 10:30am blood plt smr-very low plt ct-25* [**2172-12-21**] 06:05am blood gran ct-2350 [**2172-12-20**] 10:30am blood ret aut-0.2* [**2172-12-23**] 05:24am blood glucose-168* urean-22* creat-0.8 na-141 k-4.4 cl-105 hco3-25 angap-15 [**2172-12-22**] 07:00am blood glucose-151* urean-25* creat-0.9 na-140 k-4.2 cl-105 hco3-26 angap-13 [**2172-12-21**] 06:05am blood glucose-177* urean-23* creat-0.9 na-142 k-4.0 cl-106 hco3-26 angap-14 [**2172-12-20**] 10:30am blood glucose-101 urean-23* creat-1.0 na-141 k-4.0 cl-105 hco3-26 angap-14 [**2172-12-22**] 07:00am blood alt-18 ast-14 ld(ldh)-292* alkphos-68 totbili-1.0 [**2172-12-23**] 05:24am blood calcium-8.7 phos-4.0 mg-2.3 brief hospital course: 65 y.o. woman with follicular lymphoma and pancytopenia admitted to icu for rituximab desensitization. ##. rituximab desenitization: several weeks ago pt endorsed fatigue, lightheadedness. she underwent bone marrow biopsy which showed a recurrence of her follicular lymphoma. given her thrombocytopenia and adverse effects on other regimens pt was admitted for rituximab desensitization. she was originally admitted to the bmt floor and then transferred to the [**hospital unit name 153**] for close airway monitoring given her prior reactions to rituximab of throat itchiness, htn, rigors. she was seen by allergy who recommended a desensitization protocol of 48hrs of methylprednisolone 40mg q6hr followed by h2 blocker, benadryl with desensitization goal dose of 600mg. during and after desensitization pt did not experience any adverse reactions. she was then discharged home after the oncology team had seen her. her oncologist's office will call her for an appointment to initiate rituximab. ##. pancytopenia: pt has been pancytopenic over the past few weeks likely [**1-27**] lymphoma given her recent bm biopsy results. pt underwent bone marrow biopsy on [**12-20**] with cytogenetics for mds work-up which was still pending at time of discharge. on the bmt floor she received 2u of prbc and 1u plts. her hct remained stable albeit at a level of 22. prior to discharge pt was given another unit of prbcs. she will need to follow up with her oncologist for her bone marrow biopsy results for mds. ##. boop: she was continued on her home regimen of symbicort. ##. peripheral neuropathy: attributed to vincristine exposure, she was continued on her home regimen of gabapentin. ##. hyperlipidemia: she was continued on home regimen of simvastatin. ##. hypothyroidism: she was continued on home regimen of levothyroxine. medications on admission: budesonide-formoterol [symbicort] - (prescribed by other provider) - dosage uncertain epoetin alfa [epogen] - (prescribed by other provider) - 40,000 unit/ml solution - 60,000 units q7d gabapentin - (prescribed by other provider) - 100 mg capsule - 2 capsule(s) by mouth twice a day levothyroxine - (prescribed by other provider) - 50 mcg tablet - 1 tablet(s) by mouth once a day lorazepam - (prescribed by other provider) - dosage uncertain simvastatin - (prescribed by other provider) - 20 mg tablet - 1 tablet(s) by mouth once a day medications - otc calcium - (prescribed by other provider) - dosage uncertain docusate sodium [colace] - (prescribed by other provider) - dosage uncertain multivitamin - (prescribed by other provider) - dosage uncertain discharge medications: 1. gabapentin 100 mg capsule sig: two (2) capsule po bid (2 times a day). 2. symbicort 160-4.5 mcg/actuation hfa aerosol inhaler sig: two (2) puffs inhalation [**hospital1 **] (). 3. epogen 20,000 unit/ml solution sig: 60,000 units injection once a week. 4. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 5. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 6. multivitamin capsule sig: one (1) capsule po once a day. discharge disposition: home discharge diagnosis: primary: rituximab desensitization secondary: pancytopenia, anemia requiring blood transfusion, neutropenia 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 for the initiation of the rituximab medication for your follicular lyphoma. as you have a history of allergic reactions to this medication you underwent a 2 day protocol to be desensitized to this medication, you were able to tolerate a full dose without any allergic reactions. as your blood and platelet counts were low you were also given blood and platelet transfusions. we made on changes to your medication. if you experience any fevers, chills, extreme shivering, throat itching, swelling or difficulty breathing please return to the ed or call your doctor. followup instructions: your oncologist will call you for an appointment to start your rituximab.",0
84,"admission date: [**2194-2-28**] discharge date: [**2194-3-5**] service: neurology allergies: patient recorded as having no known allergies to drugs attending:[**first name3 (lf) 618**] chief complaint: l sided numbness and collapse major surgical or invasive procedure: mri/mra cta history of present illness: the patient is a 88yo r-handed man with asthma who is transferred from worcerster (st. vincents) after he received iv tpa for a stroke, due to lack of availability of icu bed available in [**hospital1 1559**]. he was fine this am when he woke up. while making breakfast at 8.45 am, he all of a sudden noted numbness throughout his l-leg and l-arm. his face felt fine. he slumped to the floor. he did not have tingling, and denies weakness. he felt lightheaded at the time. this has since resolved. he was able to get to the phone with some effort to call 911, and was brought to osh. nihss at osh was 12 (2 for facial, 3 for l arm, 4 for l leg, 1 for atxia, senosry and dysarthria each). fs was 110, bp 144/91. ct head was normal apart from small amount of atrophy. iv tpa was given at 11.27 (5.8mg as bolus then 52 mg in remaining hour). he was then transferred here and remained stable throughout transport. he has not been able to move his l-leg and arm and he continues to have a l-facial droop. his language has been fine. sensation on the l-side (arm and leg) is impaired as well. ros: denies any fever, chills, weight loss, visual changes, hearing changes, headache, neckpain, nausea, vomiting, dysphagia, bowel-bladder dysfunction, chest pain, shortness of breath, abdominal pain, dysuria, hematuria, or bright red blood per rectum. head ct osh per report: negative past medical history: - asthma - oa, s/p knee surgeries - macular degeneration r-eye - exophoria social history: occupation: retired salesman; has masters in history, recently obtained smoking: no; ethoh: 2 bourbon every day; drug abuse: no. level of activity: walks without assistance; drives, does checkbook widowed, 2 children. lives in [**hospital1 1559**] in apartment, alone. family history: cad physical exam: vitals: tafbebr hr 70 bp167/84 rr18 so2 99 gen: nad heent: mmm neck: no lad; no carotid bruits; limited rom neck lungs: clear to auscultation bilaterally heart: regular rate and rhythm, normal s1 and s2 abdomen: normal bowel sounds, soft, nontender, nondistended extremities: no clubbing, cyanosis, ecchymosis, or edema mental status: awake and alert, cooperative with exam, normal affect. oriented to place, month, day, and date, person. attention: moybw. memory: registration: [**1-25**] items; recall [**1-25**] at 5 min. language: fluent; repetition: intact; naming intact; comprehension intact; no dysarthria, no paraphasic errors. writing: intact. [**location (un) **]: intact; prosody: normal. fund of knowledge normal; no apraxia. no neglect, though starts naming objects on the r side. cranial nerves: ii: visual fields are full to confrontation, pupils equally round and reactive to light both directly and consensually, 3-->2 mm bilaterally. disc margins sharp, no pappilledema on the l. iii, iv, vi: extraocular movements intact without nystagmus. fixation and saccades are normal. no ptosis. v: facial sensation intact to light touch and pinprick. vii: l-facial droop, umn pattern viii: hearing intact to finger rub bilaterally. ix: palate elevates in midline. xii: tongue protrudes in midline, no fasciculations. [**doctor first name 81**]: sternocleidomastoid and trapezius normal bilaterally. motor system: normal bulk and tone bilaterally. no adventitious movements, no tremor, no asterixis. l-arm and l-leg 0/5 in all groups. does show triple flexion in l-leg upon touching reflexes: b t br pa pl right 2 2 2 0 0 left 2 2 2 0 0 grasp present on the r. toes: up on the l, down on the r sensory system: vibration decreased in both le up to the knees. able to feel cold on l side, though less than on the r. not able to feel lt and proprioception on the l side (arm and leg; face is fine) coordination: normal [**last name (lf) 11140**], [**first name3 (lf) **] on the r. gait: deferred pertinent results: 140 104 12 95 agap=13 ----------< 4.1 27 0.7 ck: 236 mb: 23 mbi: 9.7 trop-t: 0.86 ca: 8.6 mg: 2.1 p: 3.5 wbc6.9 plt210 hct38.7 n:78.8 l:11.8 m:8.6 e:0.7 bas:0.1 pt: 12.0 ptt: 29.9 inr: 1.0 tsh 1.4 b12 201 chol 221 triglyc 94 hdl 43 chol/hd 5.1 ld 159 ecg baseline artifact.sinus rhythm. complete right bundle-branch block with right axis deviation. possible underlying inferior q wave myocardial infarction. probable left atrial abnormality. non-specific st-t wave changes could be due to ischemia, etc. with biphasic t waves in lead v3. compared to the previous tracing of [**2194-3-2**] no diagnostic change. [**2194-2-28**] non-contrast head ct: there is no hemorrhage, mass, hydrocephalus, shift of normally midline structures.there is loss of grey-white differentiation in right posterior frontal lobe indicative od early infarct. areas of hypoattenuation are seen within the periventricular and subcortical white matter reflecting chronic microvascular disease. mucosal thickening is seen within the left maxillary and ethmoid sinuses. the remainder of the paranasal sinuses remain normally aerated. no osseous abnormalities are detected. calcific density is seen within the left frontal region posterior to the orbit, likely a chronic finding. impression: early infarct right posterior frontal lobe at the convexity. no intra- or extra- axial hemorrhage. cta 1. evolving right parietal lobe infarction. attenuation of branches of the superior right middle cerebral artery supplying this region. no significant stenosis or aneurysm involving the major tributaries of the circle of [**location (un) 431**]. 2. atherosclerotic disease involving the common carotid bifurcations bilaterally without evidence of hemodynamically significant stenosis. 5-mm intraluminal thrombus identified within the right internal carotid artery just distal to the bifurcation. 3. medialization of the right vocal cord with enlargement of the piriform sinus suggestive of right vocal cord paresis. clinical correlation is recommended. 4. degenerative changes within the cervical spine with anterolisthesis of c3 on c4 and c4 on c5. [**2194-3-4**] ct of the head without contrast: there is no evidence of intracranial hemorrhage, hydrocephalus or shift of normally midline structures. again noted, an area of hypoattenuation within the high right parietal lobe consistent with evolving infarction involving the right middle cerebral and anterior cerebral arteries. motion artifact degrades the quality of study. again noted, large fat containing cystic structure within the occipital scalp likely represents a sebaceous cyst. visualization of the paranasal sinuses demonstrate mild mucosal thickening involving the left maxillary sinus. impression: evolving right parietal lobe infarction. no evidence of intracranial hemorrhage. no evidence of new strokes. [**2194-2-28**] l wrist plain films: impression: severe diffuse osteopenia limits sensitivity for detecting acute fracture. deformity of the distal radius and proximal carpal rows is likely secondary to changes from chronic osteoarthritis, however an acute on chronic injury is not entirely excluded. [**2194-3-3**] cxr probable lll pneumonia echocardiogram: the left atrium is dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild regional left ventricular systolic dysfunction with basal to mid inferolateral/inferior akinesis. overall left ventricular systolic function is mildly depressed. tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. brief hospital course: the patient is an 88yo r-handed man with asthma, ?htn, ?cholesterol elevated, remote smoker, positive fh for mi, who had acute onset of leftsided weakness, then slumped to the floor. at osh (st. vincents) he had l arm/leg > face weakness and dysarthria in addition to l sided sensory change. iv tpa was given without significant improvement and he was transferred for post tpa icu care. on exam here, he hasprofound weakness l-arm/leg>>l face, sensoryloss in the l-leg and arm, though not for all modalities. toe on the l is up. he has no significant ms changes and and no visualfield loss. sequential imaging studies have demonstrated evolution of stroke in the r parietal lobe initially evident in r aca territory and then more clearly also involving the rmca territory. cta shows attenuation of branches of the superior right middle cerebral artery supplying this region, in addition to a 5-mm intraluminal thrombus within the right internal carotid artery just distal to the bifurcation. etiology of stroke either related to hypoperfusion in setting of stenosis or embolic event from [**country **] clot. aspirin added and patient treated with heparin transitioning to coumadin in view of [**country **] clot. inr 2.0 today. continuing iv heparin for further 24h to ensure therapeutic inr. then cease heparin. goal ptt 50-70. goal inr 2.0-3.0. hyperlipidaemia and statin added. there has been little additional recovery during admission aside from mild improvement in l facial weakness. follow up with dr [**last name (stitle) **] has been arranged. cvs: nstemi was diagnosed on admission here. ecg showed rbbb and possible q wave infarct. serial enzymes demonstrated troponin decline. echocardiogram showed mild midinferolateral/inferior akinesis with mildly reduced ef and 1+ mr. cardiology team recommended addition of beta blocker (but note possible adverse reaction below) and recommend addition of ace inhibitor at some stage. cardiology follow up locally. resp/id: acute respiratory decompensation on [**2194-3-3**]. clinically acute asthma exaccerbation with decreased bs l side and mild wheeze. responded to albuterol and oxygen. beta blocker ceased. cxr showed small lll pneumonia. commenced 7 days treatment with ciprofloxacin from [**2194-3-3**]. fen: vitamin b12 low and replacement folate/b12/thiamine. videoswallow and recommendations to advacne to po diet thin liquids and ground consistency solids with supervised meals. pills crushed in purees. needs full slt evaluation. gi and dvt prophylaxis observed. medications on admission: - albuterol and flovent prn - no asa discharge medications: 1. acetaminophen 325 mg tablet [**month/day/year **]: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for fever. 2. folic acid 1 mg tablet [**month/day/year **]: one (1) tablet po daily (daily). 3. hexavitamin tablet [**month/day/year **]: one (1) cap po daily (daily). 4. simvastatin 10 mg tablet [**month/day/year **]: two (2) tablet po daily (daily). 5. cyanocobalamin 500 mcg tablet [**month/day/year **]: four (4) tablet po daily (daily). 6. lansoprazole 30 mg tablet,rapid dissolve, dr [**last name (stitle) **]: one (1) tablet,rapid dissolve, dr [**last name (stitle) **] daily (daily). 7. albuterol sulfate 0.083 % solution [**last name (stitle) **]: one (1) inhalation q4-6h (every 4 to 6 hours) as needed. 8. ipratropium bromide 0.02 % solution [**last name (stitle) **]: one (1) inhalation q6h (every 6 hours) as needed for sob. 9. ciprofloxacin 500 mg tablet [**last name (stitle) **]: one (1) tablet po q12h (every 12 hours) as needed for pneumonia for 7 days: started on [**2194-3-3**], final day [**2194-3-10**]. 10. aspirin 81 mg tablet, chewable [**month/day/year **]: one (1) tablet, chewable po daily (daily). 11. warfarin 5 mg tablet [**month/day/year **]: one (1) tablet po hs (at bedtime). 12. senna 8.6 mg tablet [**month/day/year **]: one (1) tablet po bid (2 times a day) as needed for constipation. 13. bisacodyl 5 mg tablet, delayed release (e.c.) [**month/day/year **]: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 14. potassium & sodium phosphates [**telephone/fax (3) 4228**] mg packet [**telephone/fax (3) **]: one (1) packet po tid (3 times a day) for 3 doses. 15. thiamine hcl 100 mg/ml solution [**telephone/fax (3) **]: one (1) injection daily (daily). 16. heparin (porcine) in d5w 100 unit/ml parenteral solution [**telephone/fax (3) **]: one (1) 600 intravenous asdir (as directed) for 1 days: 600units /hour ptt drawn at 5pm, result to be advised. check ptt q12h goal 50-70. continue for 1 day until inr demonstrated therapeutic. discharge disposition: extended care facility: [**hospital6 1970**] - [**hospital1 1559**] discharge diagnosis: r aca/mca ischaemic stroke in context of r ica stenosis and intraluminal clot nstemi asthma exaccerbation in association with beta blocker treatment lll pneumonia discharge condition: stable. persistent dysarthria, l facial weakness (slightly improved) and static l arm and leg hemiplegia. improving lll pneumonia. discharge instructions: take medications and keep appointments as detailed below. please notify your doctor of new concerns regarding confusion, worsening speech difficulties, weakness or altered sensation. followup instructions: provider: [**first name11 (name pattern1) **] [**last name (namepattern4) 72016**], m.d. phone:([**telephone/fax (1) 72017**] date/time: neurology: dr [**last name (stitle) **] [**name (stitle) 23**] [**location (un) 858**] [**5-20**] 3.30pm. please obtain referral from pcp and call to confirm appointment [**telephone/fax (1) 72018**] local cardiologist. [**name6 (md) **] [**name8 (md) **] md, [**md number(3) 632**]",1
85,"admission date: [**2154-4-20**] discharge date: [**2154-4-24**] date of birth: [**2075-11-27**] sex: f service: medicine allergies: augmentin / atacand attending:[**first name3 (lf) 443**] chief complaint: osh transfer for stemi major surgical or invasive procedure: cardiac cath history of present illness: 78yo female with multiple medical problems including type 2 diabetes mellitus, coronary artery disease, hyperlipidemia, hypertension, peripheral vascular disease, and aaa was transferred from an osh with a stemi. . in [**2-15**], patient recently fell at home from ""legs buckling under her because of neuropathy"" and was sent to rehab. while in rehab, she tripped on the stairs and broke her ankle with no subsequent surgical intervention. at rehab, she endorsed 2 separate episodes of epigastric burning over the past 2 weeks that lasted a short amount of time and was relieved by oxygen and vomiting. today she had another episode which she describes as an epigastric type burning sensation associated with nausea and vomiting. the character of the episode was similar to the previous episodes; however this episode lasted longer. she also endorsed pain radiating to her back and shortness of breath. . upon initial evaluation by ems at 11:09am, her vital signs were hr 58, bp 92/48, rr 16, and 88% on 2l. she was taken to [**hospital 28941**] and arrived at 12:15pm. upon arrival at [**hospital3 **], vital signs were bp 131/53, hr 86, rr 18, temp 98.4, and pulse ox 100% (unclear how much supplemental o2 she received). she received sl ng x 1, asa 325mg po x 1, nitro gtt at 10mcg, dilaudid .5mg iv x 1, plavix 660mg po x 1, and heparin drip. ecg at the osh demonstrated ste in ii, iii, and avf with reciprocal std in i, avl, v1, and v2. . she was med flighted to [**hospital1 18**] where she was transferred to the cath lab and received aspirin 325mg po, heparin bolus, integrelin, and potassium. she was found to have a subtotal occlusion in the mid left circumflex for which she received a bare metal stent. . of note, she was admitted to [**hospital1 18**] on [**2151-3-15**] for a cardiac catheterization and she was found to have 95% stenosis of her left circumflex with a ""miniscule"" rca with 30% mid segment stenosis. . patient is on oxygen at baseline for copd-usually 2l but recently increased to 2.5l. she also endorsed increased lower extremity swelling since her ankle fracture 3 weeks ago. she describes leg weakness and chronic back pain. . on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. she denies recent fevers, chills or rigors. she denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for presence of chest pain, dyspnea on exertion, ankle edema, but absence of palpitations, paroxysmal nocturnal dyspnea, orthopnea, syncope or presyncope. past medical history: 1. hypertension 2. hyperlipidemia 3. type 2 diabetes mellitus 4. h/o tobacco abuse 5. peripheral vascular disease 6. abdominal aortic aneurysm 7. asthma 8. breast cancer - treated with right mastectomy and tamoxifen 9. copd . cardiac risk factors: diabetes, dyslipidemia, hypertension . pacemaker/icd: not applicable social history: social history is significant for the absence of current tobacco use. pt quit smoking in [**2136**]. there is no history of alcohol abuse. there is no family history of premature coronary artery disease or sudden death. she is a widower and lives alone. she has three sons and a daughter. family history: . - mother - cad at age 70yo; died at age 82yo from cva - sister - rheumatic [**name (ni) 3495**] disease - died from heart problems at age 49 - sister - cabg in her 60s physical exam: vs - t 96 hr 57 bp 122/53 rr 18 100%4l gen: wdwn elderly female in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 7 cm but obese habitus. cv: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. chest: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab but anteriorly abd: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. ext: no c/c, 3+ peripheral edema to b/l knees. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. 6x5 inches of indurated hematoma in right groin. . pulses: right: carotid 2+ femoral 2+ popliteal 1+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ popliteal 1+ dp 1+ pt 1+ pertinent results: admission labs [**2154-4-20**] 04:52pm blood wbc-13.3* rbc-3.30* hgb-8.8* hct-27.6* mcv-84 mch-26.8* mchc-31.9 rdw-15.3 plt ct-621* [**2154-4-20**] 04:52pm blood glucose-126* urean-16 creat-0.7 na-143 k-4.5 cl-101 hco3-35* angap-12 [**2154-4-20**] 04:52pm blood ck-mb-notdone ctropnt-0.06* [**2154-4-20**] 04:52pm blood calcium-8.7 phos-4.7* mg-1.9 [**2154-4-21**] 08:01am blood caltibc-174* vitb12-253 folate-14.9 ferritn-23 trf-134* [**2154-4-21**] 08:01am blood triglyc-168* hdl-20 chol/hd-4.2 ldlcalc-29 reports/imaging 3/14cath comments: 1. selective coronary angiography of this left dominant system revealed one vessel coronary artery disease. the lmca had no angiographically apparent disease. the lcx had a subtotal 95% occlusion at the mid vessel. the lad had minimal diffuse disease throughout. the rca was nondominant, small vessel without any angiographically apparent disease. 2. limited resting hemodynamics revealed moderate systemic hypertension with a central pressure of 160/67 mmhg. 3. successful primary angioplasty (direct stenting) of the mid lcx with a 3.0x18 mm vision bms. final angiography revealed 0% residual stenosis without dissection or distal emboli. final diagnosis: 1. one vessel coronary artery disease. 2. moderate systemic hypertension. 3. successful bms stenting to lcx. . [**2153-4-22**] the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. there is basal inferior/infero-lateral hypokinesis with overall preserved left ventricular ejection fraction (lvef>55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened. there is a minimally increased gradient consistent with minimal aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild to moderate ([**2-8**]+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. brief hospital course: 78yo female with a history of multiple medical problems including type 2 diabetes mellitus, hypertension, and peripheral vascular disease was admitted with stemi and had a bare metal stent placed to the left circumflex. . #. cad now s/pstmei: has multiple risks for cad as detailed above. her history of multiple episodes of epigastric pain appears most consistent with unstable angina. patient had ste in inferior region but has left dominant system. patient had bms to lcx and now is chest pain free. she was continued on aspirin. although patient was concerned about starting statin because of prior myopathy on different formulations, she agreed to try crestor which she tolerated without adverse reaction. fasting lipid panel showed ldl at goal. started acei at low dose and no adverse reaction so increased to 5mg po qday. also started metoprolol at 12.5 mg po bid which she tolerated well. . #hematoma: patient developed a 6x4 inch hematoma in right groin s/p cath. her hematocrit droped initially and required 3 units of blood. throughout this she was hemodynamically stable. her hematocrit stabilized and hematocrit checks were done only daily. . #. pump: patient appears mildly hypervolemic on admission but difficult to assess secondary to body habitus and post cath flat positioning. patient was previously on multiple anti-hypertensive agents at her rehab facility, including hydralazine, ccb, and nitrate. patient was transitioned to acei and beta blocker regimen given that she was post stemi. she had an echocardiogram that showed preserved ef and inferior/infero-lateral hypokinesis. slowly resumed home furosemide after she was stabilized. . #. rhythm: patient remains slightly bradycardic but in normal sinus rhythm. her heart rate improved after mi to be normocardic. she was monitored on telemetry via cardiology protocol without events. . #. type 2 diabetes mellitus: a1c on admission was 6% which was at goal. continued home insulin which was long acting lantus in house, 20u at night. did not require any insulin on sliding scale. discontinued actos as it was not needed based on in house blood sugars. #. vitamin d deficiency:stable, continue vitamin d supplementation . #. gerd:stable-continue prevacid . #. glaucoma- continue xalatan eye drops and genteal eye drops . #. copd: on 2l oxygen at baseline- continue xopenex, flovent, and atrovent . #. anxiety: continued 0.25mg po prn alprazolam as patient was stable on home regimen. . #. pain: c/o back pain chronically worsened with lying flat post cath, continue gabapentin 100mg po qhs, percocet prn pain. . #. right ankle fracture: seen by pt and walking boot applied. pt states this feels heavy but is able to participate in pt. she has wbat on this ankle and pain is well controll with percocet prn. medications on admission: 1. levemir 20 units sc qhs 2. diltiazem 300mg po daily 3. vitamin d 800 units po daily 4. actos 15mg po qam 5. prevacid 30mg po daily 6. xalatan eye gtt 2 drops ou qhs 7. gabapentin 100mg po qhs 8. xopenex inh q4h prn 9. tylenol 325-650mg po q4h prn 10. mom 30ml po daily prn 11. lasix 80mg po daily (recently increased from 40mg daily on [**2154-4-3**]) 12. potassium 20meq po daily 13. imdur 30mg po daily 14. flovent 1 puff [**hospital1 **] 15. xopenex tid prn 16. atrovent inh qid standing 17. hydralazine 10mg po qid 18. xanax .25mg qhs discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. insulin detemir 100 unit/ml solution sig: twenty (20) units subcutaneous at bedtime. 5. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 6. gabapentin 100 mg capsule sig: one (1) capsule po hs (at bedtime). 7. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for constipation. 8. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 9. levalbuterol hcl 0.63 mg/3 ml solution for nebulization sig: one (1) ml inhalation q8h prn () as needed for shortness of breath. 10. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation qid (4 times a day). 11. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 12. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: [**2-8**] drops ophthalmic prn (as needed). 13. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). disp:*15 tablet(s)* refills:*2* 14. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 15. xanax 0.25 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia. 16. furosemide 80 mg tablet sig: one (1) tablet po daily (daily). 17. fluticasone 110 mcg/actuation aerosol sig: one (1) puff inhalation [**hospital1 **] (2 times a day). 18. rosuvastatin 20 mg tablet sig: two (2) tablet po daily (daily). 19. lisinopril 5 mg tablet sig: two (2) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 20. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 21. miconazole nitrate 2 % powder sig: one (1) appl topical [**hospital1 **] (2 times a day) as needed. 22. magnesium oxide 400 mg tablet sig: one (1) tablet po twice a day for 2 [**hospital1 4319**]. discharge disposition: extended care facility: [**hospital1 66324**] discharge diagnosis: st elevation myocardial infarction coronary artery disease diabetes mellitus type 2 glaucoma chronic obstructive pulmonary disease anxiety discharge condition: stable discharge instructions: you had a heart attack and required a cardiac catheterization to assess the arteries that feed blood to your heart. one of these arteries were blocked and you received a bare metal stent to this artery. you have been started on plavix and it's very important that you take plavix every day for one month. do not miss [**first name (titles) 691**] [**last name (titles) 4319**] or stop taking plavix unless dr.[**name (ni) 3733**] tells you to. you developed a large collection or blood in your right groin after the sheaths were taken out in the catheterization lab. this was controlled by holding pressure on your right groin. you needed to have some blood transfusions to replace the blood that was lost. we have changed the following medicines: 1. plavix: to keep the stent from clotting off 2. lisinopril: to lower your blood pressure 3. metoprolol: to lower you heart rate and help your heart recover from the heart attack. 4. rosuvastatin: to decrease cholesterol levels. 2. stop taking hydralazine, actos and diltiazem . please call dr. [**last name (stitle) **] if you notice any more swelling or bruising at the right groin site, if you develop a fever or cough, if you have chest pain or trouble breathing or for any other unusual symptoms. followup instructions: primary care: [**last name (lf) **],[**first name7 (namepattern1) **] [**initial (namepattern1) **] [**last name (namepattern4) 66325**]:[**telephone/fax (1) 66326**] cardiology: dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] phone: [**hospital3 25148**] center [**hospital1 66327**] [**location (un) **], [**numeric identifier 66328**] telephone: ([**telephone/fax (1) 66329**] date/time: [**5-2**] at 1:00pm endocrinology: dr. [**first name (stitle) 66330**] [**name (stitle) **] phone: phone: ([**telephone/fax (1) 66331**] [**hospital1 66332**] center, [**location (un) **] nh completed by:[**2154-4-24**]",0
86,"admission date: [**2199-3-8**] discharge date: [**2199-3-11**] date of birth: [**2153-12-17**] sex: f service: medicine allergies: erythromycin base / flagyl attending:[**first name3 (lf) 106**] chief complaint: transfer from [**hospital **] hospital with shortness of breath major surgical or invasive procedure: none history of present illness: 45 yo female w/ hx of of svt (? avnrt vs avrt) who presented to osh six days post-partum with shortness of breath. patient states that she noticed being short of breath with exertion for several days prior to her delivery six days ago. she then had an uncomplicated vaginal delivery on [**2199-3-2**]. no hypertension, pre-eclampsia during her pregnancy. placenta was normal. patient noticed increasing shortness of breath in the days following delivery, which became acutely worse 2-3 days ago. she noticed decreased exercise tolerance and soon was short of breath just walking across the room. also noted orthopnea and could not sleep lying flat. she denies chest pain, cough, hemoptysis. no fevers or chills. no syncope. had some rhinorrhea a few weeks ago, which had completely resolved. . at osh patient was noted to be hemodynamically stable. she had a cta which was negative for pe but did demonstrate bilateral pleural effusions and evidence of pulmonary edema. she had an echo performed - ef 15%, mild lv enlargement, global hypokinesis, mr 2+, tr 2+. patient was given lasix 20 mg iv x 2, digoxin 0.5 mg iv x 1, nitro paste, and was started on a heparin gtt. she was transferred to [**hospital1 18**] for further evaluation. . on arrival here, she was feeling relatively well. denied shortness of breath at rest. no chest pain. past medical history: paroxysmal svt - has had episdoes of svt for 20+ years, usually last a few minutes, had one prolonged episode which persisted overnight. she was treated with digoxin and metoprolol in the past. during her pregnancy she was treated with labetolol, although had discontinued at some point in the last nine months. patient reports that she can always feel when her tachycardia starts and stops, sometimes has dizziness associated with it. has never had syncope/loss of consciousness. social history: lives in [**hospital1 **] with her husband. stopped working [**2-22**] pregnancy, but she was working on an assembly line prior to delivery. no etoh. former smoker - smoked 1/2ppd for 20+ years, wuit 8 yrs ago. family history: father - mi in 50s, then developed a cardiomyopathy that resulted in a hreat transplant in late 60s mother - breast ca daughter - post-partum cardiomyopathy folloing her first pregnancy physical exam: gen: nad, comfortable, speaking in full sentences heent: perrla, op - clear, mmm neck: neck veins flat, no lad lungs: decreased breath sounds at right base, bilateral crackles ni the lower thirds of her lungs card: reg, + s3, [**2-26**] sys murmur @ apex abd: + bs, mildly distended, mildy tender to palp over supra-pubic area ext: dp 2+ bilat, no edema neuro: alert and oriented x3, sensation and motor function grossly intact, cn ii-xii intact. pertinent results: labs: [**2199-3-8**] 10:54pm blood wbc-15.6* rbc-4.10* hgb-13.0 hct-36.7 mcv-90 mch-31.7 mchc-35.4* rdw-14.1 plt ct-430 [**2199-3-8**] 10:54pm blood neuts-76.5* lymphs-15.8* monos-7.1 eos-0.5 baso-0.2 [**2199-3-8**] 10:54pm blood glucose-109* urean-16 creat-0.6 na-141 k-3.4 cl-103 hco3-25 angap-16 [**2199-3-8**] 10:54pm blood alt-48* ast-33 ck(cpk)-80 alkphos-137* totbili-0.3 [**2199-3-8**] 10:54pm blood ctropnt-<0.01 [**2199-3-8**] 10:54pm blood calcium-9.2 phos-4.1 mg-2.2 iron-27* [**2199-3-9**] 06:19am blood calcium-9.7 phos-4.0 mg-2.4 cholest-343* [**2199-3-8**] 10:54pm blood caltibc-484* ferritn-35 trf-372* [**2199-3-9**] 06:19am blood triglyc-151* hdl-119 chol/hd-2.9 ldlcalc-194* [**2199-3-8**] 10:54pm blood tsh-1.8 [**2199-3-9**] 06:19am blood hcv ab-negative . ekg: 84 bpm, sinus rhythm. t wave inversion in leads vi-v2 with st-t wave flattening in leads i and avl. the right precordial t wave inversion may be a normal variant. . chest (portable ap) [**2199-3-9**] 1:19 pm the cardiomediastinal silhouette is within normal limits. there is no chf or effusion. there is some prominence of interstitial markings in the right cardiophrenic angle, without frank consolidation. compared with earlier the same day, there has been considerable improvement at right base and in the small amount of right costophrenic sulcus blunting. rapid improvement suggests that this represent residua from earlier chf. correlation with clinical symptoms is requested for full assessment. . chest (portable ap) [**2199-3-9**] 12:19 am the heart is not enlarged. the aortic contour and superior mediastinum are within normal limits. there is no upper zone redistribution to suggest chf. there is some patchy increased density at the right base which could represent a pneumonic infiltrate. no frank consolidation is identified. thereis possible minimal blunting of the right costophrenic angle. otherwise, no effusions are seen. impression: patchy opacity in the right lower lobe medially, which could represent an infectious infiltrate. possible minimal blunting of the right costophrenic angle. no chf or gross effusion. . tte [**2199-3-9**]: lvef 25%. the left atrium is mildly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. there is severe global left ventricular hypokinesis. overall left ventricular systolic function is severely depressed. [intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] transmitral doppler and tissue velocity imaging are consistent with grade iii/iv (severe) lv diastolic dysfunction. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. brief hospital course: 45 yo female w/ hx of paroxysmal svt who presents with worsening shortness of breath since her delivery on [**2199-3-2**]. seen at osh and found to have significantly depressed ef and global hypokinesis. . 1. chf: patient presenting with shortness of breath and depressed ef 6 days post-partum. given time of onset, most likely has developed post-partum cardiomyopathy. viral cardiomyopathy is another possible cause of her presentation given recent uri symptoms. hcv ab was negative and the patient reports a negative hiv test recently done during prenatal course. her triglycerides were also not highly elevated. the patient has a history of paroxysmal svt, however given the short duration of these symptoms, their symptomatic nature, it is unlikely that she would have had a persistent extended episode of tachycardia resulting in cardiomyopathy. she has a normal tsh making hypothyroidism unlikely and a normal ferritin and iron level making hemochromatosis unlikely. ischemia is another cause for her symptoms although it is unlikely given normal cardiac enzymes and few risk factors for heart disease in this patient. digoxin and nitropaste which were started at the osh were discontinued. echo showed hypokinesis but no akinesis and heparin was discontinued. she was treated with aspirin, lisinopril, low dose beta blocker, statin, and lasix. . 2. hx of paroxysmal svt: she presented to [**hospital1 18**] in sinus rhythm and was monitored on telemetry. . 3. leukocytosis: although she had leukocytosis, she was afebrile and without localizing signs or symptoms of infection. urine and blood cultures were negative. leukocytosis was most likely [**2-22**] recent delivery. . 4. post-partum: vaginal bleeding has been mild/moderate. she was started on an acei for cardiomyopathy and was advised not to breast feed given the potential adverse side effects of this medication in infants. the patient reports that she understands the adverse reactions and will not breast feed. . 5. code: full. medications on admission: prenatal vitamins discharge medications: 1. aspirin 81 mg tablet, chewable sig: two (2) tablet, chewable po daily (daily). disp:*60 tablet, chewable(s)* refills:*2* 2. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. metoprolol succinate 25 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). disp:*30 tablet sustained release 24hr(s)* refills:*2* 4. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily) for 1 months. disp:*30 tablet(s)* refills:*0* 6. lasix 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 7. outpatient lab work check chem 10 in 1 week. have results sent to dr.[**name (ni) 12389**] office, ([**telephone/fax (1) 7437**] discharge disposition: home discharge diagnosis: post partum cardiomyopathy discharge condition: good, ambulatory, respiratory status stable discharge instructions: please take all medications as directed. . you will be taking some medications that are important for your heart but are not compatible with breast feeding. please do not breast feed. . if you develop shortness of breath, chest pain, palpitations, or any other symptoms that concerns you, call your doctor or go to the emergency room. followup instructions: make a follow up appointment with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 6073**] for [**1-22**] weeks from now. you can call his office at ([**telephone/fax (1) 7437**] . make an appointmet to get a transthoracic echo in 1 month. the phone number is ([**telephone/fax (1) 19380**]. . have your lab work checked in 1 week.",1
87,"admission date: [**2167-4-28**] discharge date: [**2167-7-2**] date of birth: [**2114-1-22**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**first name3 (lf) 2181**] chief complaint: transferred from osh with hypoxic respiratory failure major surgical or invasive procedure: intubation tunneled hd line placement hemodialysis picc placement, picc removal history of present illness: this is a 53 year-old woman with history of cad, chf, copd on home oxygen, pulm hypertension, polysubstance abuse who presented to osh earlier today ([**4-28**]) with altered mental status. as per records, patient presented after her vna noted medical non-compliance and apparent overuse of sedating medications and summoned ems. when patient arrived at osh, the patient was somewhat confused and hypoxic to high 80's on 3 liters. (unclear baseline requirement but on home oxygen). also tachycardic to 100, tachypneic to mid 20's and hypertensive to 160's. she had low grade fevers to 99. she was felt to be in congestive heart failure, was noted to have hyperkalemia, and apparently new renal failure with creatinine in 6's. a central line was placed but then the patient became agitated, self-extracted the femoral line. serial haldol, benadryl and ativan x3 were not effective in sedating her and therefore the patient was intubated for airway protection. the femoral line was replaced. the patient had a ng tube placed, was given kayxelate, calcium gluconate, bicarb, insulin, and glucose for hyperkalemia, las well as lasix for chf. she was given a dose of levoquin for uti/possible pneumonia. the patient had an anion gap acidosis and there was concern for ethylene glycol because ""urate crystals"" were noted in the urine. . she was noted to have coffee grounds by ngt. . the patient was transferred to [**hospital1 18**] er. in our er, received a tox consult, renal consult, gi consult and cxr. the cxr confirmed chf. flomipazole was given for possible ethylene glycol intoxication. renal recommended: no dialysis, give bicarb. gi recommended: protonix, ffp and vitamin k. tox: no other reccs. . vitamin k 10 subcut, 2 units ffp, protonix, insulin, dextrose, calcium gluconate, kaexelate and bicarb given. . past medical history: (per osh records) 1. copd-on 4l o2 by nc at home 2. pulmonary hypertension 3. cad 4. chf--diastolic dysfunction 5. anxiety 6. polysubstance abuse 7. pvd s/p l aka social history: lives alone in [**doctor last name **], has a visiting nurse. family history: unknown physical exam: admission exam vs: temp: 97.5 bp:154/65 hr:89 rr:24 100%o2sat vent: ac 550x24, fio2 of 1, peep of 10. i/o: 150/400 in our emergency department general: intubated, sedated heent: pupils equal, minimally responsive, anicteric, mmm, op without lesions, no supraclavicular or cervical lymphadenopathy lungs: crackles [**12-9**] way up heart: rr, s1 and s2 wnl, no murmurs, rubs or gallops appreciated but difficult to appreciate abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly extremities: no cyanosis, clubbing or edema. left aka skin/nails: no rashes/no jaundice/ neuro: intubated, sedated pertinent results: [**2167-4-28**] 08:30pm blood -wbc-19.5* rbc-4.94 hgb-13.1 hct-41.0 mcv-83 mch-26.5* mchc-31.9 rdw-18.5* neuts-83.7* bands-0 lymphs-10.3* monos-5.7 eos-0.2 basos-0.1 pt-28.5* ptt-30.6 inr(pt)-3.0* plt smr-high plt count-449*; hypochrom-1+ anisocyt-2+ poikilocy-normal macrocyt-normal microcyt-normal polychrom-1+ -asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-pos osmolal-313* ctropnt-0.08* ck(cpk)-231* glucose-101 urea n-105* creat-6.5* sodium-130* potassium-6.8* chloride-98 total co2-16* anion gap-23* [**2167-4-28**] 08:39pm glucose-92 lactate-1.3 k+-6.3* . [**2167-4-28**] 09:00pm urine eos-negative; rbc-[**5-17**]* wbc-21-50* bacteria-many yeast-none epi-[**5-17**]; blood-mod nitrite-neg protein-30 glucose-neg ketone-tr bilirubin-sm urobilngn-neg ph-5.0 leuk-sm; color-yellow appear-hazy sp [**last name (un) 155**]-1.020 [**2167-4-28**] 09:00pm urine bnzodzpn-neg barbitrt-neg opiates-pos cocaine-neg amphetmn-neg mthdone-neg; osmolal-376 [**2167-4-28**] 09:35pm type-art po2-60* pco2-45 ph-7.23* total co2-20* base xs--8 [**2167-4-28**] 10:55pm urea n-109* creat-6.5* sodium-135 potassium-6.2* chloride-102 total co2-17* anion gap-22* . [**2167-5-30**] wbc-9.3 hgb-11.0* hct-34.3* mcv-86 mch-27.6 mchc-32.0 rdw-23.8* plt ct-314 [**2167-6-10**] wbc-13.1* hgb-9.3* hct-30.1* mcv-93 mch-28.5 mchc-30.8* rdw-24.0* plt ct-425 [**2167-6-23**] wbc-19.0* hgb-10.7* hct-34.2* mcv-91 mch-28.2 mchc-31.1 rdw-22.1* plt ct-640* [**2167-6-24**] wbc-18.0*hgb-10.7* hct-32.8* mcv-87 mch-28.5 mchc-32.6 rdw-21.6* plt ct-578* [**2167-6-27**] wbc-16.7* hgb-11.0* hct-35.7* mcv-91 mch-28.2 mchc-30.9* rdw-21.2* plt ct-482* [**2167-6-28**] wbc-19.0* hgb-11.4* hct-36.3 mcv-91 mch-28.5 mchc-31.4 rdw-20.9* plt ct-503* . micro: -urine cultures ([**4-28**], [**5-1**], [**5-6**]): no growth. . -sputum ([**4-29**]): 3+ gram positive cocci in pairs and clusters. -sputum ([**5-1**]): 1+ yeast. . -blood ([**4-30**], [**5-1**], [**5-6**], [**5-15**], [**5-18**], [**6-22**]): negative. -blood ([**6-24**], off antibx): no growth to date. -blood ([**5-14**]): one bottle with staph coagulase negative. . -catheter tip ([**5-6**]): no growth. -catheter tip ([**5-13**]): no growth. -catheter tip ([**5-22**], [**5-26**], [**6-20**]): no growth. . -hemodialysis catheter blood cx ([**6-18**]): no growth. . -stool ([**5-8**], [**5-10**], [**5-11**], [**5-31**], [**6-27**]): c. diff. negative. . -blood ([**5-22**]): rpr negative. . [**4-30**] echo the left atrium is normal in size. the right atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. . [**5-1**] ct torso impression: 1. no bowel obstruction is identified. small bowel and large bowel loops appear unremarkable. 2. bilateral increased interstitial markings and septal thickening is suggestive of presence of the heart failure. the heart is also mildly enlarged. 3. small bilateral pleural effusions and dependent atelectatic changes are noted at both lung bases. infiltrate/infection cannot be ruled out. small pericardial effusion is also noted. 4. a 4-mm nodule is noted within the anterior portion of the right middle lobe. pathologically enlarged right paratracheal node measures 13 mm in the short axis. 5. diverticulosis with no evidence of diverticulitis. 6. the aorta demonstrates severe stenosis below the renal arteries. no aneurysmal dilatation is noted. 7. small right kidney with normal sized left kidney. no hydronephrosis or stones are identified. . [**5-1**] ct head 1. no acute intracranial abnormality. 2. chronic infarcts in the right cerebellum and centrum semiovale. 3. sinus disease involving left maxillary and sphenoid sinuses. . [**5-2**] eeg impression: this is an abnormal eeg due to the presence of probable periodic lateralizing epileptiform discharges (i.e., pleds) involving the right hemisphere which could indicate a subcortical abnormality involving this area. the presence of a diffusely slow background and disorganized background is consistent with a mild to moderate encephalopathy of toxic, anoxic, or metabolic etiology. the occasional sharp waves can be a sign of cortical irritability, but clinical correlation would need to be provided. no evidence for ongoing seizures is seen. . [**5-19**] echo/bubble study: focused study to assess for patent foramen ovale. images were obtained at rest, with cough and post-valsalva release with injection of agitated saline. no evidence for an atrial septal defect or patent foramen ovale was identified. there is symmetric left ventricular hypertrophy with preserved global systolic function. no pericardial effusion is seen. . [**5-25**] mr spine: 1. multilevel degenerative changes of the lower lumbar spine, most pronounced at the l4-5 and the l5-s1 levels respectively.2. type [**first name9 (namepattern2) **] [**last name (un) 13425**] changes of the l4 and l5 vertebral bodies respectively. 3. no evidence of epidural abscess. . [**6-10**] chest cta:1. no definite evidence of pulmonary embolus. 2. cardiomegaly, pleural effusions, and pulmonary edema, all consistent with congestive heart failure.3. right upper and right middle lobe pulmonary nodules, little change since [**2167-5-1**]. six-month followup chest ct is recommended to assess stability.4. mediastinal lymphadenopathy, likely reactive. . [**6-15**] echo bubble: saline contrast study performed to assess for intracardiac shunt. no passage of agitated saline is seen into the left heart is identified. the left ventricular cavity is normal in size. there appears to be global hypokinesis that is more pronounced/worse that the study of [**2167-5-19**]. . [**6-19**] echo: the left atrium is elongated. the right atrium is moderately dilated. the estimated right atrial pressure is [**4-16**] mmhg. left ventricular wall thicknesses and cavity size are normal. there is moderate to severe global left ventricular hypokinesis (lvef = 30 %). systolic function of apical segments is relatively preserved. no masses or thrombi are seen in the left ventricle. the right ventricular cavity is moderately dilated with mild globalfree wall hypokinesis. the aortic valve leaflets are mildly thickened. mild to moderate ([**12-9**]+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of [**2167-4-30**], global left ventricular systolic function is more depressed and the right ventricular cavity is mildly dilated and hypokinetic. the estimated pulmonary artery systolic pressure is higher. . [**6-22**] ct of the chest without iv contrast: there is no axillary lymphadenopathy. there is pretracheal lymphadenopathy measuring up to 1.5 cm. this is unchanged. there are small bilateral effusions. these are stable. again noted is an ovoid nodule in the apex of the right lung measuring 1.2 x 0.5 cm. this is stable in appearance. there are tiny nodules in the right lung. these are again stable. there is diffuse septal thickening which is unchanged. in the presence of cardiomegaly this is consistent with chf. ct of the abdomen without iv contrast: the liver is without focal lesions. the gallbladder has been removed. spleen, pancreas, adrenal glands are unremarkable. the right kidney is atrophic. the left kidney has some bulging of the contour at mid pole measuring about 1.6 cm. this is difficult to evaluate on the prior study as there is significant artifact from the patient's body touching the gantry but is likely present. there is no retroperitoneal lymphadenopathy. small and large bowel are normal. ct of the pelvis without iv contrast: the uterus is normal in size and contains some calcified fibroids. there is diverticulosis of the sigmoid colon. there is no adjacent inflammatory fat stranding. there is no free fluid in the pelvis. no pelvic adenopathy is noted. on bone windows, there are degenerative changes involving the lumbar spine. impression: 1. no findings to explain the patient's symptoms. the examination is essentially unchanged in comparison to prior studies. 2. interstitial prominence and small bilateral pleural effusions with cardiomegaly are consistent with chf. again this is stable. 3. mediastinal adenopathy unchanged. . [**6-23**] ruq us:1. no focal fluid collections. 2. atrophic right kidney consistent with chronic renal failure. . [**2167-6-30**] 4:18p other blood chemistry: hbsag: negative hbs-ab: negative hbc-ab: negative [**2167-4-29**] 05:41pm report comment: source: line-hemodialysis hepatitis hepatitis b surface antigen negative hepatitis b surface antibody positive hepatitis b virus core antibody negative hepatitis c serology hepatitis c virus antibody positive brief hospital course: discharge summary (as of [**2167-5-27**]) assessment and plan: this is a 53 year old woman with coronary artery disease, congestive heart failure, copd, pulmonary hypertension, s/p l aka who is oxygen dependent on nasal canula 4 liters at home, and polysubstance abuse who presented to [**hospital3 35813**] center in [**state 792**]with altered mental status, hypoxia, and agitation. she was intubated for airway protection and transferred to [**hospital1 18**]. course complicated by anuric renal failure requiring dialysis. . 1)mental status change: most likely multifactorial, as patient with previous polysubstance abuse. chronic small vessel disease noted on head ct. eeg negative for seizure activity. per family, patient lives alone and able to care for herself and perform activities of daily living. on admission, toxicology screen revealed opiates and tricyclics, and by medical notes on transfer, patient had been using more sedating medications than normal. neurology evaluated patient and vitamin b12 and folate levels were normal. she received thiamine. tsh level was elevated to 8 and her t4 was only very slightly below normal. thus, thyroid function was not attributed to altered mental status. an eeg revealed encephalopathy, but no seizures. ct head revealed chronic small vessel disease. lp and mri were deferred. -upon extubation, patient slowly became more alert, first with purposeful eye tracking and then by following simple commands. she received haldol and ativan, which sedated her profoundly for several days. then, after extubation, she began to have conversations but with frequent outbursts with cursing at times, poor attention and short term memory. she became febrile on [**2167-5-7**], which was concerning for a line infection, and was treated initially with vanco/zosyn changed to vanco/meropenem plan for 3 day course complete [**2167-5-9**]. c. diff negative x3. her head ct was unchanged. on [**5-13**], patient had her picc line and tunneled hd line placed and developed fevers within 12 hours. only one blood culture from [**5-14**] revealed one bottle of staph coagulase negative organisms. treated with ten day course of vancomycin (per hd protocol) through [**5-23**]. -lexapro was restarted on [**2167-5-12**], but held on [**5-22**]. psychiatry continued to follow patient and for continued outbursts recommended haldol 0.5mg po/iv three times daily. as above, concern that heavy sedatives with ativan and haldol cause profound sedation. she required soft wrist restraints for prevention of line removal. pt was transferred to the micu on [**6-2**] for respiratory compromise (see below). -upon arriving at the floor on [**6-5**] the patient was aox3, but with residual confusion, impulse control issues, and aggitation. her course was complicated by recurrent episodes of aggitation and anxiety which were hard to control. she perseverated on her medications, her course, and her dietary restrictions. psych was consulted and attempted to help control these outbursts without using benzodiazepems. she often complained of dyspnea, but requested ativan as treatment. she was transferred to the micu for low o2 saturation, where she was diuresed for congestive heart failure/volume overload. she was transferred back to the floor on [**6-15**], where she continued to be anxious and take off her o2 mask. psych recommended continuing standing haldol as well as 100mg neurontin qhs. benzodiazepines were avoided. this combination had a calming effect and the patient was significantly less agitated without being over-sedated, thought to be back to her baseline mental status. remained at baseline mental status for the rest of the hospitalization . 2) respiratory compromise: at outside hospital, patient was hypoxic to high 80's on 3l. at home, she requires 4l nasal canula. patient has history of copd, chf, and pulmonary hypertension per outside notes. intubated on transfer and thought that congestive heart failure contributed to hypoxemic event. no clear pneumonia. patient was aggressively diuresed via hemodialysis. she was extubated on [**5-7**]. hypoxia seems out of proportion to edema demonstrated on imaging. tte was negative for patent foramen ovale. . on [**2167-6-1**], the patient triggered for hypoxia 68% on 6 liters (the patient formerly had been 90-92% on 6 liters. on recheck, the o2 sat was 88% and then 90-91% on 6 liters without intervention. the patient was scheduled to have hd as scheduled on [**2167-6-2**]. . at hd, the hd catheter was noted to be nonfunctioning. tpa was tried without success. then, the patient was found to be hypoxic to 75% at hd with abg 7.53/26/44 0on a 40% venti mask. on a nrb, the patient's saturations improved to 97% and a repeat gas was 7/53/27/58. . the patient denied any chest pain and says the shortness of breath was not acute in onset but had been developing over the past few days. however, her sbp was noted to be 188-216 during hd and the patient was given her am bp meds as a result. cxr indicated volume overload and pt. was thought to have had acute pulmonary edema [**1-9**] hypertension and inability to dialyze. pt was transferred to micu and had temporary femoral hd line initially placed, then tunneled hd line placed by ir [**6-3**]. she had 7l removed during micu course with improvement of oxygenation and was sent back to floor [**6-5**]. . while on the floor she was maintained on 6l of nc. she did occasionally complain of dyspnea and anxiety, however it was hard to differentiate this from her psychiatric issues, as she was often breathing at a normal rate and sat'ing in the mid 90s while complaining. she generally maintained saturations from 88-95%. she did have at least two desat's into the low 80s at night, but responded within minutes to reassurance and haldol without changing any pulmonary medications or oxygen. on [**6-9**] she had an episode of somlenence and increased confusion after her haldol had been increased to 2mg/dose and her nc o2 dropped to 4l. she was somlenent but arousable, and still oriented to self she recovered mental status quickly after a 50% venti mask was placed, and was then seen by the micu staff. she was transferred again to the micu at that point, and again was diuresed aggressively with good result. repeat tte again showed no patent foramen ovale/shunt. cta was negative for pe. . she was transferred back to the floor on [**6-15**], where she continued to required 6-8 l o2 and occasionally desat'd in setting of anxiety. an echo [**6-19**] showed evidence of worsening chf (ef 30% now, was >55% in [**month (only) **]), which would explain continued increased oxygen requirement and sob, with evidence of pulmonary edema on cxr. in conjunction with the renal team, the patient required almost daily hd or ultrafiltration to draw off fluid. attempts were made with medications to balance the need for afterload reduction with supporting a blood pressure which could tolerate volume loss through dialysis. this primarily involved decreasing the patient's betablocker and verapamil dose significantly, while maintaining isosorbide nitrate. the patient was witnessed several times eating high salty foods, and being non-compliant with the fluid restriction which complicated attempts to manage her volume status. with aggressive hd, as well as improved management of her anxiety and aggitation (above) the patient gradually was weaned down to her baseline requirement of 4l o2 on nasal cannula. . 3) anuric renal failure: atn likely from tca/opiate overdose. outside hospital records revealed creatinine of 4.0 in [**month (only) 958**] [**2166**]. on admission, anuric. she was hyperkalemic, so initially received kayxelate, calcium gluconate, insulin, and bicarbonated. no ecg changes. renal ultrasound negative for obstruction. received aggressive hemodialysis sessions. there was concern that tunneled dialysis line infected, but as she was not rigoring and did not ever develop fever or hypotension except when on dialysis, believed that filter on hemodialysis machine may have caused adverse reaction. asaghi filter used on [**5-22**] with good effect. . management of the patient's volume status was complicated by dietary noncompliance and aggitation. after requiring 2 micu transfers from the floor due to decreased oxygen saturation from pulmonary edema, we were finally able to dialyze her sufficiently to bring her back to baseline oxygen requirement. we monitored her intake carefully and impressed upon her the importance of dietary compliance. adding neurontin to her anxiety regimen helped calm her and she became more compliant with our management strategy and was less likely to take off her oxygen support. renal recommends performing a 24 hour urine collection after one month to re-evaluate her renal status. . 4) cardiovascular: --ischemia: history of coronary artery disease. as outpatient, on aspirin but no beta blocker or ace-inhibitor. ecg without ischemic changes and initial cardiac enzymes negative. continued aspirin and added beta blocker. --pump: evidence of pulmonary edema and congestive heart failure on admission. as anuric, removed excess fluid with hemodialysis. --rhythm: remained in sinus rhythm. started on beta blockade. --hypertension: severely elevated blood pressures. started amlodipine, metoprolol, and isorbide. goal blood pressure <170, but due to longstanding hypertension, developed worsened mental status when blood pressures less than 140. most likely due to hypoperfusion. in setting of hypotensive episodes during dialysis, held antihypertensives on mornings of dialysis. over the course of hospitalization, we adjusted her bp medications according to what was tolerated during dialysis. on discharge, she is taking isosorbide mononitrate 30mg sr and toprol xl 100mg q day. . 5) gi: on admission, apparent ugi bleeding. coffee grounds in ngt but this was in setting of supratherapeutic inr. subsequently resolved status post reversal of inr. treated with iv (and then po) protonix. her serial hematocrits remained stable. abdominal ct on [**5-1**] unremarkable. diverticulosis was noted on subsequent abdominal ct (as above). . 6) infectious disease: on admission, received levofloxacin, but then broadened to zosyn and vancomycin for uti. completed seven day course on [**5-5**]. shortly after discontinuation of antibiotics, was transiently febrile, so started meropenem and vancomycin on [**5-7**] for 3 day course. picc line was placed and tunneled hd line placed on [**5-13**]. febrile shortly after line placed (1/4 bottles with staph coagulase negative), so started ten day course of vancomycin that was completed on [**5-23**]. new picc placed [**6-3**] for antibiotics and question of infection. on [**6-17**] id was consulted for rising leukocytosis. bacillus species grew from [**6-19**] picc blood cx, pt was started on cefepime for bacteremia on [**6-20**] (initial culture result said gnr) and picc was d/c'd. was discovered on [**6-23**] that bacillus likely was a contaminant. pt has been afebrile, but given persistently high wbc, there was concern for infection or other etiology. [**6-18**] culture from hd catheter had no growtn. c. diff was negative. antibiotics were discontinued on [**6-23**] given no organism isolated and patient being afebrile. subsequent culture from [**6-24**] showed no growth to date. can consider other cause of leukocytosis: patient was not on systemic steroids so that is unlikely to be a cause. patient had mediastinal lymphadenopathy and lung nodules, which could suggest a malignant cause. recommend working up malignancy as outpatient given that patient is clinically stable and would benefit from rehab placement. . 7) depression: on outpatient lexapro. restarted during hospitalization, but discontinued, per psychiatry, on [**5-22**]. . 8) prophylaxis: patient on sc heparin (was on coumadin as outpatient, but unclear reason), lansoprazole, bowel regimen, and thiamine. . 9) access: picc placed on [**5-13**], but removed [**5-22**]. tunneled hemodialysis catheter placed on [**5-13**]. picc placed [**6-3**], removed [**6-21**]. . 10) fen: initially on tubefeeds. speech and swallow evaluation on [**5-18**] cleared patient for thin liquids and pureed solids. aspiration precautions. eventually advanced to regular renal diet. occasionally was hyponatremic, thought due to excess free water ingestion. was kept on fluid restriction 1l/day, with varying effect as patient would sometimes obtain water/fluids when the nurse was not looking. . 11) rash: patient noted to have morbilliform rash on trunk and flank on evening of [**5-25**]. most likely result of drug reaction. potentially vancomycin. started on hydrocortisone cream, sarna lotion, and triamcinolone cream. resolved. pt also noted to have intragluteal irritation with sattelite lesions, likely yeast infection. started on miconazole powder. . 12) code: full. confirmed with daughter. (in the past patient had said she wanted to be dnr/dni but then reversed this). . communication: daughter, [**name (ni) **] - [**telephone/fax (1) 72819**]. . dispo: to . has outpatient hd slot at [**location (un) 37361**] for mwf. medications on admission: unsure of doses--from [**hospital1 **] records 1.aspirin 2.hydralazine 3.imdur 4.amytriptyline 5.lexapro 6.ativan 7.advair 8.combivent 9.albuterol 10. lasix 11. coumadin 12. cardizem discharge medications: 1. aspirin 325 mg tablet [**hospital1 **]: one (1) tablet po daily (daily). 2. polyvinyl alcohol-povidone 1.4-0.6 % dropperette [**hospital1 **]: [**12-9**] drops ophthalmic prn (as needed). 3. lansoprazole 30 mg tablet,rapid dissolve, dr [**last name (stitle) **]: one (1) tablet,rapid dissolve, dr [**last name (stitle) **] daily (daily). 4. docusate sodium 100 mg capsule [**last name (stitle) **]: one (1) capsule po bid (2 times a day) as needed: hold for diarrhea. 5. senna 8.6 mg tablet [**last name (stitle) **]: one (1) tablet po bid (2 times a day) as needed: hold for diarrhea. 6. lactulose 10 g/15 ml syrup [**last name (stitle) **]: thirty (30) ml po q8h (every 8 hours) as needed: hold for diarrhea. 7. albuterol sulfate 0.083 % (0.83 mg/ml) solution [**last name (stitle) **]: one (1) inhalation q4h (every 4 hours) as needed for wheezing. 8. acetaminophen 325 mg tablet [**last name (stitle) **]: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 9. thiamine hcl 100 mg tablet [**last name (stitle) **]: one (1) tablet po daily (daily). 10. b complex-vitamin c-folic acid 1 mg capsule [**last name (stitle) **]: one (1) cap po daily (daily). 12. fluticasone-salmeterol 250-50 mcg/dose disk with device [**last name (stitle) **]: one (1) inh, disk with device inhalation [**hospital1 **] (2 times a day). 13. budesonide 0.25 mg/2 ml solution for nebulization [**hospital1 **]: one (1) neb inhalation [**hospital1 **] (2 times a day). 14. nystatin 100,000 unit/ml suspension [**hospital1 **]: five (5) ml po qid (4 times a day). 15. isosorbide mononitrate 30 mg tablet sustained release 24 hr [**hospital1 **]: one (1) tablet sustained release 24 hr po daily (daily). 16. haloperidol 1 mg tablet [**hospital1 **]: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for anxiety or aggitation. 17. albuterol sulfate 0.083 % (0.83 mg/ml) solution [**hospital1 **]: one (1) neb ih inhalation q6h (every 6 hours) as needed. 18. tramadol 50 mg tablet [**hospital1 **]: one (1) tablet po q12h (every 12 hours) as needed. 19. lidocaine 5 %(700 mg/patch) adhesive patch, medicated [**hospital1 **]: one (1) adhesive patch, medicated topical q24h (every 24 hours). 20. ipratropium bromide 0.02 % solution [**hospital1 **]: one (1) neb inhalation q6h (every 6 hours) as needed. 21. haloperidol 2 mg tablet [**hospital1 **]: one (1) tablet po tid (3 times a day). 22. zolpidem 5 mg tablet [**hospital1 **]: 1-2 tablets po hs (at bedtime). 23. miconazole nitrate 2 % powder [**hospital1 **]: one (1) appl topical qid (4 times a day) as needed. 24. sevelamer 400 mg tablet [**hospital1 **]: one (1) tablet po tid w/meals (3 times a day with meals). 25. gabapentin 100 mg capsule [**hospital1 **]: one (1) capsule po hs (at bedtime): hold for oversedation. 26. toprol xl 100mg tablet [**hospital1 **]: one (1) tablet po once a day discharge disposition: extended care facility: banister house discharge diagnosis: congestive heart failure , acute on chronic renal failure discharge condition: discharge to banister house in [**hospital1 789**], ri, stable, afebrile, good po intake, wheelchair bound [**1-9**] amputation discharge instructions: please seek medical attention for shortness of breath, chest pain, dizzyness, headache please take your medications as prescribed. followup instructions: please get a repeat chest ct in 6 months to monitor the r upper and middle pulmonary nodules. . please get a 24 hour urine test to evaluate your kidney in one month completed by:[**2167-7-2**]",1
88,"admission date: [**2123-3-7**] discharge date: [**2123-3-18**] date of birth: [**2066-2-1**] sex: f service: medicine allergies: lasix / penicillins attending:[**first name3 (lf) 2159**] chief complaint: sepsis; coag negative staph bacteremia, ?line associated dka stemi major surgical or invasive procedure: none history of present illness: ms. [**name13 (stitle) **] is a 57 yo woman with severe copd, chf (unknown ef), dm2, was found by her niece to be unresponsive sitting in stool around [**3-6**], sent to osh- found to be septic with fever to 103.2, hypotensive to 70/36, positive ua (lg nit, lg le, >100wbc, many bacteria). she was treated with vancomycin, levaquin. she was also found to be in dka with hyperglycemia to 735 and ag of 17. she was given 3l fluid, insulin gtt. transferred to [**hospital1 18**] where first ekg shows st elevation in iii and avf with diffuse st-t changes elsewhere. troponin positive at 0.2, ck of 274. in [**hospital1 18**] ed, she was started on asa 325mg, plavix 300mg, heparin gtt, cards consulted and felt that this may represent inferior st elevation mi, and recommended medical therapy with no acute catheterization given other acute medical illness with dka and sepsis. levophed gtt and insulin gtt 8u/hr and vanc/zosyn initiated. right ij sepsis line placed. dka resolved and transitioned to lantus. subsequently remained chest pain free. cx. from osh grew [**3-14**] coag negative staph. was transitioned from zosyn to levaquin, and completed vanco course for transient cons bacteremia, which rapidly cleared (negative cultures at [**hospital1 18**]), and indwelling line was pulled. . of note, she reports a severe adverse reaction to lasix, which resulted in ""welts"" and skin sloughing. this was thought to be another potential source of the transient coag neg staph bacteremia. past medical history: 1. severe copd 2. chf 3. dm2; patient reports not being on prior meds or insulin therapy. documented as previously on glyburide in [**12-15**]. 4. h/o urosepsis w/ e. coli 5. h/o chronic back pain social history: reports >40pack x year smoking history; denies any current tobacco use. denies etoh or other drug abuse. lives with parent and adult son. disabled secondary to chronic low back pain. family history: not elicited physical exam: vs: 98.7, 80, 88/39, 21, 99% 4l nc . gen alert, oriented, appears disheveled heent very dry mucous membranes neck r ij catheter, full neck; unable to assess jvd cv rrr, no m/r/g resp distant breath sounds, no focal findings, wheeze, or crackles abd obese, soft, nt, nabs rectal: guaiac neg brown stool extr: firm, indurated, lichenified skin and pigmentation changes in bilateral lower extremities neuro no gross deficits pertinent results: [**2123-3-7**] 10:51pm type-mix [**2123-3-7**] 10:51pm glucose-110* [**2123-3-7**] 10:51pm hgb-10.1* calchct-30 o2 sat-60 [**2123-3-7**] 09:35pm type-mix [**2123-3-7**] 09:35pm k+-3.2* [**2123-3-7**] 09:35pm hgb-9.2* calchct-28 o2 sat-49 [**2123-3-7**] 09:01pm ptt-39.8* [**2123-3-7**] 03:30pm ptt-38.2* [**2123-3-7**] 12:01pm comments-green top [**2123-3-7**] 12:01pm lactate-1.0 [**2123-3-7**] 11:35am glucose-113* urea n-45* creat-1.7* sodium-136 potassium-3.9 chloride-103 total co2-25 anion gap-12 [**2123-3-7**] 11:35am ld(ldh)-239 ck(cpk)-157* [**2123-3-7**] 11:35am ck-mb-3 ctropnt-0.08* [**2123-3-7**] 11:35am calcium-7.3* phosphate-1.9* magnesium-2.2 [**2123-3-7**] 11:35am wbc-12.6* rbc-3.19* hgb-10.1* hct-30.4* mcv-95 mch-31.6 mchc-33.3 rdw-17.8* [**2123-3-7**] 11:35am plt count-118* [**2123-3-7**] 08:31am type-mix [**2123-3-7**] 08:31am lactate-1.4 [**2123-3-7**] 07:50am lactate-1.5 k+-3.0* [**2123-3-7**] 06:55am ptt-34.2 [**2123-3-7**] 06:20am lactate-1.6 [**2123-3-7**] 05:48am lactate-1.6 [**2123-3-7**] 04:27am alt(sgpt)-20 ast(sgot)-28 ld(ldh)-237 ck(cpk)-200* alk phos-93 amylase-23 tot bili-0.4 [**2123-3-7**] 04:27am lipase-21 [**2123-3-7**] 04:27am cortisol-76.9* [**2123-3-7**] 04:27am urine hours-random urea n-427 creat-25 sodium-68 [**2123-3-7**] 04:27am urine osmolal-397 [**2123-3-7**] 04:27am wbc-14.2* rbc-3.26* hgb-10.1* hct-30.3* mcv-93 mch-31.2 mchc-33.5 rdw-18.0* [**2123-3-7**] 04:27am neuts-94.6* bands-0 lymphs-3.3* monos-1.9* eos-0.1 basos-0 [**2123-3-7**] 04:27am plt count-107* [**2123-3-7**] 04:27am pt-13.4* ptt-34.2 inr(pt)-1.2* [**2123-3-7**] 04:27am urine color-straw appear-clear sp [**last name (un) 155**]-1.012 [**2123-3-7**] 04:27am urine blood-lg nitrite-neg protein-tr glucose-1000 ketone-tr bilirubin-neg urobilngn-neg ph-5.0 leuk-sm [**2123-3-7**] 04:27am urine rbc-21-50* wbc-[**11-30**]* bacteria-few yeast-none epi-1 [**2123-3-7**] 04:27am urine eos-negative [**2123-3-7**] 04:16am type-mix [**2123-3-7**] 04:16am lactate-1.4 k+-2.8* [**2123-3-7**] 03:06am type-mix [**2123-3-7**] 03:06am lactate-1.3 [**2123-3-7**] 03:06am hgb-11.2* calchct-34 o2 sat-65 [**2123-3-7**] 02:11am glucose-292* lactate-1.5 k+-3.1* [**2123-3-7**] 02:00am glucose-291* urea n-59* creat-2.1* sodium-133 potassium-3.1* chloride-94* total co2-25 anion gap-17 [**2123-3-7**] 02:00am calcium-7.5* phosphate-2.9 magnesium-1.8 [**2123-3-7**] 02:00am wbc-14.3* rbc-3.35* hgb-10.7* hct-31.8* mcv-95 mch-32.0 mchc-33.7 rdw-17.8* [**2123-3-7**] 02:00am neuts-90* bands-5 lymphs-1* monos-4 eos-0 basos-0 atyps-0 metas-0 myelos-0 [**2123-3-7**] 02:00am plt count-135* [**2123-3-6**] 11:35pm glucose-286* urea n-63* creat-2.4* sodium-131* potassium-2.7* chloride-91* total co2-23 anion gap-20 [**2123-3-6**] 11:35pm estgfr-using this [**2123-3-6**] 11:35pm ast(sgot)-17 alk phos-101 amylase-27 tot bili-0.4 [**2123-3-6**] 11:35pm lipase-45 [**2123-3-6**] 11:35pm albumin-2.7* calcium-7.6* phosphate-2.2* magnesium-1.9 [**2123-3-6**] 11:35pm wbc-11.9* rbc-3.40* hgb-11.0* hct-31.9* mcv-94 mch-32.3* mchc-34.4 rdw-17.8* [**2123-3-6**] 11:35pm neuts-90* bands-4 lymphs-2* monos-3 eos-0 basos-0 atyps-0 metas-1* myelos-0 [**2123-3-6**] 11:35pm plt count-121* [**2123-3-6**] 11:35pm pt-13.2* ptt-24.3 inr(pt)-1.2* chest (portable ap) [**2123-3-6**] 11:43 pm impression: 1. mild pulmonary vascular congestion without overt chf. renal u.s. impression: 1. no stones or hydronephrosis. 2. echogenic liver consistent with fatty infiltration. other forms of liver disease including hepatic fibrosis/cirrhosis cannot be excluded. 1.2 cm lesion in the right lobe of the liver which may represent a hemangioma. further evaluation with mr is recommended. echo ([**3-8**]) patient/test information: indication: left ventricular function. height: (in) 66 weight (lb): 205 bsa (m2): 2.02 m2 bp (mm hg): 100/49 hr (bpm): 80 status: inpatient date/time: [**2123-3-8**] at 13:23 test: portable tte (complete) doppler: full doppler and color doppler contrast: none tape number: 2007w00-0: test location: west micu technical quality: adequate referring doctor: dr. [**first name11 (name pattern1) **] [**initial (namepattern1) **] [**last name (namepattern1) **] measurements: left atrium - long axis dimension: *4.5 cm (nl <= 4.0 cm) left atrium - four chamber length: *6.0 cm (nl <= 5.2 cm) right atrium - four chamber length: *5.2 cm (nl <= 5.0 cm) left ventricle - septal wall thickness: 1.1 cm (nl 0.6 - 1.1 cm) left ventricle - inferolateral thickness: 1.1 cm (nl 0.6 - 1.1 cm) left ventricle - diastolic dimension: *5.7 cm (nl <= 5.6 cm) left ventricle - ejection fraction: 50% to 55% (nl >=55%) aorta - valve level: 2.8 cm (nl <= 3.6 cm) aorta - ascending: 2.7 cm (nl <= 3.4 cm) aortic valve - peak velocity: 1.6 m/sec (nl <= 2.0 m/sec) mitral valve - e wave: 0.9 m/sec mitral valve - a wave: 1.0 m/sec mitral valve - e/a ratio: 0.90 mitral valve - e wave deceleration time: 211 msec tr gradient (+ ra = pasp): *27 mm hg (nl <= 25 mm hg) interpretation: findings: left atrium: mild la enlargement. right atrium/interatrial septum: mildly dilated ra. left ventricle: normal lv wall thickness. mildly dilated lv cavity. suboptimal technical quality, a focal lv wall motion abnormality cannot be fully excluded. overall normal lvef (>55%). no resting lvot gradient. no vsd. right ventricle: normal rv chamber size and free wall motion. aorta: normal aortic diameter at the sinus level. normal ascending aorta diameter. aortic valve: mildly thickened aortic valve leaflets (3). no as. no ar. mitral valve: mildly thickened mitral valve leaflets. mild (1+) mr. tricuspid valve: mildly thickened tricuspid valve leaflets. mild [1+] tr. borderline pa systolic hypertension. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets with physiologic pr. pericardium: no pericardial effusion. conclusions: the left atrium is mildly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity is mildly dilated. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is probabaly normal (lvef 50-55%). the distal lv and apex are not well seen (in some views, the septum and inferior walls appear hypokinetic). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. impression: overall lvef is preserved. cannot exclude a regional wall motion abnormality due to sub-optimal images. if clinically indicated, a repeat study with echo contrast (definity) would better characterize regional and global lv systolic function. repeat echo with contrast([**3-9**]): patient/test information: indication: left ventricular function. height: (in) 66 weight (lb): 205 bsa (m2): 2.02 m2 bp (mm hg): 121/70 status: inpatient date/time: [**2123-3-9**] at 11:30 test: portable tte (focused views) doppler: limited doppler and no color doppler contrast: definity tape number: 2007w005-1:31 test location: west micu technical quality: adequate referring doctor: dr. [**first name11 (name pattern1) **] [**initial (namepattern1) **] [**last name (namepattern1) **] measurements: left ventricle - ejection fraction: >= 55% (nl >=55%) interpretation: findings: this study was compared to the prior study of [**2123-3-8**]. left ventricle: normal regional lv systolic function. overall normal lvef (>55%). right ventricle: normal rv chamber size and free wall motion. pericardium: no pericardial effusion. conclusions: overall left ventricular systolic function is normal (lvef>55%), without a regional wall motion abnormality. right ventricular chamber size and free wall motion are normal. there is no pericardial effusion. impression: normal global and regional biventricular systolic function. radiology final report exercise mibi [**2123-3-11**] exercise mibi reason: chf, and stemi in setting of sepsis, dka submaximal stress with imaging radiopharmeceutical data: 10.2 mci tc-[**age over 90 **]m sestamibi rest ([**2123-3-11**]); 28.8 mci tc-99m sestamibi stress ([**2123-3-11**]); history: 57 year old woman with congestive heart failure and st elevation myocardial infarction in the setting of sepsis. summary of data from the exercise lab: exercise protocol: [**doctor last name 4001**] resting heart rate: 70 resting blood pressure: 118/60 exercise duration: 2.75 minutes peak heart rate: 95 percent maximum predicted heart rate obtained: 58% peak blood pressure: 110/60 symptoms during exercise: [**7-20**] chest tightness reason exercise terminated: patient request secondary to chest tightness ecg findings: no significant st segment changes method: resting perfusion images were obtained with tc-[**age over 90 **]m sestamibi. tracer was injected approximately one hour prior to obtaining the resting images. at peak exercise, approximately three times the resting dose of tc-[**age over 90 **]m sestamibi was administered iv. stress images were obtained approximately one hour following tracer injection. imaging protocol: gated spect this study was interpreted using the 17-segment myocardial perfusion model. interpretation: the image quality is adequate. left ventricular cavity size is large, with an estimated edv of 154 ml. resting and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. gated images reveal global hypokinesis. the calculated left ventricular ejection fraction is 43%. impression: 1. no reversible perfusion defects identified to suggest induced ischemia. 2. enlarged left ventricle with global hypokinesis. edv = 154 ml, ef = 43%. \ exercise results resting data ekg: sinus, poss laa, prwp, nssttw heart rate: 70 blood pressure: 118/60 protocol [**doctor last name **] - treadmill / stage time speed elevation heart blood rpp (min) (mph) (%) rate pressure 1 0-2.75 1.0 5 95 110/60 [**numeric identifier 72496**] total exercise time: 2.75 % max hrt rate achieved: 58 symptoms: angina peak intensity: [**7-20**] time hr bp rpp onset: 2 ex 94 110/60 [**numeric identifier 72497**] resolution: 5 rec 76 120/62 9120 st depression: none interpretation: this 57 yo woman s/p recent stemi was referred to the lab for evaluation. the patient exercised for 2.75 minutes on a [**doctor last name 4001**] protocol and stopped at the patient's request secondary to progressive chest tightness. this represents a very limited functional capacity for her age. the patient reported feeling [**7-20**] chest tightness 2 minutes into exercise which resolved completely by minute 5 of recovery. no significant st segment changes were noted during exercise or in recovery. the rhythm was sinus with 1 single isolated apb and vpb. a drop in systolic blood pressure was noted with exercise (118/60 mmhg at rest to 110/60 mmhg at peak exercise). blunted heart rate-response in the setting of beta-blockade therapy. impression: submaximal study. anginal type symptoms without ischemic ekg changes at a very low workload. abnormal blood pressure response to exercise. brief hospital course: this is a 57yo woman with h/o dmii, copd, chf, presents with urosepsis, dka, and evidence of inferior distribution [**hospital **] transferred to the micu for further care. . # sepsis: admitted with sepsis physiology, started on volume resuscitation and pressors in addition to zosyn/vanco. wbc count trended down, able to come off pressors after 1d. eventually osh cultures from [**hospital **] hospital grew [**3-14**] coag staph hominis. all cx. and follow up cx. here to date negative including urine cx. switched to levaquin from zosyn as pt. transferred to floor, then after id consult, decision was made to d/c levaquin as well, with plan of 7d of vanco after her central line d/c'd. she finished her vanco course 2d prior to d/c. . # hyperglycemia/hyperosmolar state vs. dka: the patient presented initially with marked hyperglycemia and acidosis (ag of 14). the patient was started on an insulin drip until her gap closed. she was then transitioned to lantus and hiss with a [**last name (un) 387**] consult. ag closed, transitioned to lantus upon move to floor, and started on glipizide as pt. initially refused outpt. insulin shots despite advisement that she is at risk for infection/dka. with ongoing discussion, she was convinced to take 1 shot per day (lantus), and was titrated to lantus dose of 34 upon d/c. metformin initially started but d/c'd [**2-12**] risk for lactic acidosis with cr>1.4. she was discharged on lantus 34u and 5mg [**hospital1 **] glipizide with close endocrine follow up to determine her longterm insulin needs and optimized out patient regimen. she had nutrition consult and insulin teaching here and was able to administer her shots by time of discharge. suggested vna f/u with pt., but pt. strongly stated preference to not have vna involved. . # stemi: the patient presented with a new inferior mi with q wave in iii with positive cardiac enzymes at outside hospital. the patient was placed on a heparin drip. she had one episode of cp relieved by ntg while in the micu. cards was consulted and deferred cath until transfer out of micu with resolution of infection/sepsis. she was treated medically with plavix, statin, asa, heparin. echo with preserved ef. heparin was d/c'd after 5d. stress test without reversible defect; cards recommended outpt. cath. with primary cardiologist dr. [**last name (stitle) 72498**] d/c'd on plavix, ezetimibe, asa, metoprolol and prn ntg. she declined statin therapy due to a prior adverse effect . # renal failure: baseline cr 1.5 (on diuretics and lisinopril) since last [**month (only) 321**]. admit 2.1 in context of sepsis, likely atn. renal usn showed no hydro or perinephric abscess. came down to 1.1, but rose again to 1.7 with administration of diuretics. improved to 1.4 on d/c with held diuretics, acei. she did not have any respiratory or cardiac symptoms with held diuretics x several days and did not regain significant le edema. will require close follow up of volume status to determine diuretic needs (relatively preserved ef on echo, decreased to 43% on mibi), and ?new baseline creatinine. she was instructed to keep a log of daily weights to review with her pcp/cardiologist to assist with above determinations and to call or return to hospital with any symptoms suggestive of chf (reviewed with pt). . # ?liver lesion: seen on renal u/s. per rads, should get mri to follow-up . # le edema: improved with bumex, metalazone, but d/c'd [**2-12**] increasing cr. d/c'd diuretics now given no pulmonary sx. and rising cr. . # copd: not currently active - cont. ipratroprium mdi # pt. d/c'd home. was offered vna with pt and medication/diabetic teaching, but pt. declined medications on admission: bumex 2bid metolazone 10qd asa 81 discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 3. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain. disp:*30 tablet(s)* refills:*0* 4. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation q4-6h (every 4 to 6 hours) as needed. disp:*1 aerosol* refills:*2* 5. nitroglycerin 0.3 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain: can take 1 if experiencing chest pain and can repeat after 5 minutes if pain has not resolved x2. disp:*20 tablet, sublingual(s)* refills:*0* 6. ezetimibe 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 7. toprol xl 50 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. disp:*30 tablet sustained release 24 hr(s)* refills:*0* 8. glipizide 5 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 9. lantus 100 unit/ml solution sig: thirty four (34) units subcutaneous at bedtime. disp:*5 bottles* refills:*2* discharge disposition: home discharge diagnosis: stemi diabetes mellitus diabetic ketoacidosis sepsis chf with ef of 55% discharge condition: good, taking pos, ambulating without assistance, satting >95% on ra discharge instructions: please weigh yourself daily and record your weight. should you gain more than 3 pounds, contact your primary care doctor immediately. please adhere to a low salt diet as outlined to you by nutritionist here, not to exceed 1.5g salt/day. you should not exert yourself too much, limiting activity to lifting <5 pounds and ambulating to two blocks until otherwise directed by your outpatient doctors. please seek medical attention should you develop chest pain or tightness, dizziness, lightheadedness, or nausea. please take medications exactly as prescribed, including and follow up at the below appointments. you need to take your lantus every day, as has been shown you in the hospital. please try and check your blood sugars in the morning and evening and record the numbers for your pcp to follow up. followup instructions: please follow up with dr. [**last name (stitle) **] and dr. [**last name (stitle) 4455**] within the next week: dr. [**last name (stitle) **] ([**telephone/fax (1) 72499**] at 1:30 pm monday [**3-22**] with dr. [**last name (stitle) **] at his [**hospital1 **] office. you have been started on lantus, which you should continue to take 34u each evening until otherwise directed by your pcp. [**name10 (nameis) **] should take your glucose log into your pcp and have your sugar checked there as well you have an appt. dr. [**last name (stitle) 4455**] thursday [**3-25**] at 1:45 pm you had a stress test that showed fixed defects that should be further evaluated with cardiac catheterization.",1
89,"admission date: [**2176-11-20**] discharge date: [**2176-11-23**] date of birth: [**2117-9-30**] sex: m service: ccu history of present illness: this is a 59-year-old man who was transferred to the cmi service on the [**7-21**] for a cardiac catheterization after suffering a non q wave myocardial infarction at [**hospital6 33**]. he has a long history of coronary artery disease, status post multiple interventions and multiple myocardial infarctions. his most recent catheterization was at [**hospital6 1129**] in [**2174-11-19**] and showed a 25% left main, 80% diagonal 1, 80% distal left anterior descending, 50% ramus, 40% om1, 50% right coronary and 100% pvv. percutaneous transluminal coronary angioplasty was done on the om1 and left circumflex arteries at that time. in [**2176-8-19**], he was admitted to an outside hospital for 12 hours of chest pain and ruled in for an myocardial infarction with a peak cpk of 1800. he has been asymptomatic since that time until three weeks prior to admission when he developed exertional angina that progressed to unstable angina over two to three days. his primary care physician ordered an exercise treadmill test and an echocardiogram on the [**9-13**] which showed a fixed apical defect and a mid anterior defect with an ejection fraction of 47%. while driving on [**11-19**], he noted chest pain and had incomplete relief with three sublingual nitroglycerin. at that point he called 911. he was admitted to [**hospital6 33**] and ruled in for a myocardial infarction with a cpk of 457. he was given aspirin and lovenox. he has been pain free for the past 24 hours and was transferred to [**hospital6 2018**] for catheterization on [**2176-11-20**]. catheterization showed severe three vessel disease and a left ventricular ejection fraction of 38%. he was transferred to the coronary care unit for close monitoring after catheterization. past medical history: 1. coronary artery disease, status post multiple catheterizations, status post stent times one, status post multiple myocardial infarctions. 2. hypercholesterolemia. 3. hypertension. 4. cluster migraines. medications on transfer: 1. aspirin 325 mg. 2. lovenox 80 subcutaneously b.i.d. 3. cardizem cd 240 q.d. 4. lipitor 10 mg po q.d. 5. paxil 10 mg po q.d. 6. multivitamin. 7. sublingual nitroglycerin prn. 8. fiberall prn. 9. vitamin c 500 mg q.d. allergies: beta-blocker causes bronchospasm. family history: positive for coronary disease and diabetes. social history: he is a divorced high school science teacher with six children who does not smoke. physical examination: this is a groggy intermittently arousable man in no acute distress with a blood pressure of 101/62 and a pulse of 73. his oxygen saturation is 98% on two liters nasal cannula. he is afebrile. his head, eyes, ears, nose and throat exam is unremarkable and he has no jugular venous distention. his lungs are clear to auscultation bilaterally. his heart is regular with distant heart sounds but no murmurs. his abdomen is benign. his extremities are without edema and with 2+ distal pulses. his neurological exam reveals that he is awake and oriented to person only. laboratories: showed a white blood cell count of 8.6, hematocrit of 46.3 and platelet count of 227,000. his chem-7 was within normal limits, notable for a potassium of 3.9, bun of 13 and a creatinine of 1.0. his glucose is 142. his coags are within normal limits. his cardiac enzymes at the outside hospital revealed cks of 209 and 457. electrocardiogram at [**hospital6 33**] revealed normal sinus rhythm at 60 beats per minute with a normal axis and normal intervals. he had diffusely flattened t wave but no acute st changes. he had qs in iii, avr and avf. after percutaneous transluminal coronary angioplasty, his electrocardiogram here was unchanged. catheterization results revealed diffuse severe three vessel coronary disease with mild systolic and diastolic dysfunction and an ejection fraction of 38%. he has moderate mitral regurgitation. he had anterolateral, apical and inferior basal akinesis with preserved inferior and anterior basal wall motion. he underwent percutaneous transluminal coronary angioplasty and stent times two to his om1. he underwent percutaneous transluminal coronary angioplasty and stenting of his mid left anterior descending and his distal left anterior descending. he had moderate instent restenosis of a right posterior descending artery stent that was unchanged from his previous catheterization in [**2174**]. he underwent a total of six percutaneous transluminal coronary angioplasties and four stents. five of the percutaneous transluminal coronary angioplasties were successful. hospital course: mr. [**known lastname **] was observed in the coronary care unit overnight given the multiple nature of his interventions and his diffuse coronary disease. he did well and by the next morning was arousable, alert and awake and oriented times three. he was continued on aspirin and lipitor. a beta-blocker could not be started due to his adverse reaction to them. he was started on plavix given the stents that he received and captopril. he developed a cough on the captopril and so it was changed to diovan. his cks peaked at 680 with an mb of 78 and an mb index of 11.5. during his catheterization, he received 615 cc of intravenous dye. despite this, his creatinine remained stable during his hospital stay between 0.9 and 1.1. a total cholesterol and hdl was checked upon admission to the hospital which showed a total cholesterol of 149 and an hdl of 46. after catheterization, he suffered some nausea and bloating that was without electrocardiogram changes and resolved after he had a bowel movement. mr. [**known lastname **] had two episodes of [**11-28**] chest pain, each lasting five minutes which resolved without intervention two nights after his catheterization. given this, he was started on isordil with no further ischemic pain. the morning after he had received isordil, however, he did note some lightheadedness. he states in the past that he thinks isordil may have caused him lightheadedness previously, but he is uncertain of this. on exam the day after his catheterization, he was noted to have bibasilar rales. on his third hospital day when he began to ambulate, he also noted some dyspnea on exertion. he was gently diuresed with a low dose lasix. this improved his symptoms. however, the next morning, as stated above, he noted some lightheadedness. it was unclear whether this was due to diuresis or preload reduction with isordil. he was advised to use lasix as needed for dyspnea on exertion and to avoid it on a regular basis or if he became lightheaded. he was also changed to imdur and advised to stop using it if he began to have lightheadedness. he has been on cardizem in the past and this was discontinued and he was switched to a long acting nitrate. a homocystine level was checked and was pending at the time of discharge. he was advised to start taking folate 1 mg q.d. condition at discharge: improved. discharge status: to home to follow-up with dr. [**first name11 (name pattern1) **] [**initial (namepattern1) **] [**last name (namepattern4) 16072**] in seven to ten days who will also set him up for cardiac rehabilitation. discharge diagnoses: 1. status post non q wave myocardial infarction. 2. history of coronary artery disease with history of multiple myocardial infarctions and multiple stent placements. 3. hypertension. 4. hypercholesterolemia. 5. migraines. discharge medications: 1. aspirin 325 mg po q.d. 2. plavix 75 mg po q.d. until [**2176-12-22**]. 3. lipitor 10 mg po q.h.s. 4. folate 1 mg po q.d. 5. diovan 80 mg po q.d. 6. imdur 60 mg po q.d. 7. paxil 10 mg po q.d. 8. nitrostat sublingual prn. [**first name8 (namepattern2) **] [**first name8 (namepattern2) **] [**name8 (md) **], m.d. [**md number(1) 7169**] dictated by:[**name8 (md) 1552**] medquist36 d: [**2176-11-27**] 10:06 t: [**2176-11-27**] 10:06 job#: [**job number **] cc:[**hospital6 99684**]",1
90,"admission date: [**2201-9-9**] discharge date: [**2201-10-5**] date of birth: [**2132-5-30**] sex: f service: neurology allergies: patient recorded as having no known allergies to drugs attending:[**first name3 (lf) 5341**] chief complaint: admit for high dose mtx- cycle 6 major surgical or invasive procedure: none. history of present illness: initial hpi: 69 yo f with mmp that is admitted for high dose mtx- cycle 6. she was admitted [**date range (1) 99695**] for a very complicated course of high dose mtx. her chemotherapy course was compicated by altered mental status with periods of aggitation and somnolence. she became vol overoaded with concern for decreased uop unresponsive to lasix and was noted to be 6 lbs heavier than admission. she then became hypotensive, bradycardic, and non-responsive with sbp 80's-90's, hr 35. her mtx level was noted to be 499. she was transferred to the micu on [**8-14**] for mtx toxicity for hd/cvvhd. she was also noted to be in acute renal failure and congestive heart failure. she was treated with hemodialysis until [**8-26**] and then lasix with good urine output. she also had some pulmonary edema which has responded to afterload reduction and diuresis. the patient has been at [**hospital3 **] in the intervenig time and no other acute issues. . pt is able to state her name, but does not know time or place. she can move her arm on command but unable to answer review of systems questions. pt had no other complaints. past medical history: past onc hx: cns lymphoma diagnosed [**2201-5-22**] with progressive word-finding difficulty, ataxia, and increasing anxiety w/ emotional lability. an mri then demonstrated an irregular enhancing mass in the cerebellum, bifrontal lobes,left temporal lobe (largest region of abnormality) and right occipital lobe. pathology on biopsy was consistent with primary high grade b cell cns lymphoma. she has a h/o seizure and is on dilantin. pt had completed 5 course of high dose mtx. . 1. diastolic dysfunction- ef >55 %. echo consistent with diastolic dysfunction. 2. cva- [**1-15**] multiple posterior circulation strokes, found to have an occluded right vertebral artery and plaque in her aorta, placed on coumadin (please see d/c summary for other details) 3. sah- [**10-15**] bilateral sah while on coumadin, taken off coumadin. has been on dilantin 4. htn 5. cad 6. obesity 7. osa on bipap 8. hypothyroidism 9. gerd social history: lived with her sister, formerly a nurse but now retired, never married, no kids, quit tob [**2178**], no etoh, no drugs. has been living at [**hospital3 **] family history: no h/o strokes physical exam: 96.2 ax 92/46 60 16 96% ra gen: nad, aaox3, speaking softly, alert to name, but not place or time, can follow simple commands but not very expressive. heent: mmm, op-no thrush, eomi cvs: rr distant heart sounds lungs: cta-b, poor insp effort abd: soft, obese, nt/nd, +bs extr: no rashes, no le edema pertinent results: [**2201-9-9**] 12:28pm glucose-100 urea n-15 creat-1.0 sodium-144 potassium-3.7 chloride-104 total co2-31 anion gap-13 [**2201-9-9**] 12:28pm alt(sgpt)-19 ast(sgot)-15 ld(ldh)-243 alk phos-235* amylase-31 tot bili-0.2 [**2201-9-9**] 12:28pm lipase-16 [**2201-9-9**] 12:28pm albumin-3.1* calcium-10.0 phosphate-4.1 magnesium-2.0 [**2201-9-9**] 12:28pm wbc-11.5*# rbc-3.24* hgb-10.0* hct-30.8* mcv-95 mch-30.9 mchc-32.5 rdw-21.6* [**2201-9-9**] 12:28pm plt count-687* [**2201-9-9**] 12:28pm pt-12.8 ptt-22.5 inr(pt)-1.1 [**2201-9-9**] 11:13am urine color-straw appear-slhazy sp [**last name (un) 155**]-1.010 [**2201-9-9**] 11:13am urine blood-neg nitrite-neg protein-neg glucose-1000 ketone-50 bilirubin-neg urobilngn-neg ph-8.0 leuk-mod [**2201-9-9**] 11:13am urine rbc-0 wbc-3 bacteria-occ yeast-none epi-<1 [**2201-9-9**] 11:13am urine amorph-occ . [**8-7**] echo: [**name prefix (prefixes) **] [**last name (prefixes) 5660**] dilated. lv size, thickness and systolic function is normal (lvef>55%). moderate pa htn. no valvular dz. . mri brain [**9-11**] - 1. continued areas of edema and enhancement in the left temporal lobe, right occipital lobe, and left cerebellar hemisphere. the lesion in the left temporal lobe appears to be slightly increased in size and the amount of edema appears to be slightly increased. however, it is unclear whether this is a real finding or it represented differences in technique. 2. no new lesions are identified. . cxr [**9-11**] - the tip of the port-a-cath lies in a good position by the junction of the svc and right atrium. there is no pneumothorax. the pulmonary edema present on [**8-26**] has resolved. . ct [**9-16**] - stable appearance of brain parenchyma. no new intracranial bleed or mass effect is identified. d/c labs: [**2201-10-5**] 12:00am blood wbc-11.3* rbc-2.76* hgb-9.1* hct-27.2* mcv-98 mch-32.8* mchc-33.3 rdw-20.6* plt ct-323 [**2201-10-5**] 12:00am blood plt ct-323 [**2201-10-5**] 12:00am blood glucose-113* urean-25* creat-0.5 na-144 k-4.2 cl-110* hco3-25 angap-13 [**2201-10-5**] 12:00am blood albumin-2.9* calcium-10.4* phos-2.4* mg-1.8 brief hospital course: this is a 69 y/o female with cns lymphoma, h/o diastolic chf, cad, osa, recently admitted for high-dose mtx complicated by hypotension, arf and chf, then readmitted on [**9-9**] for another cycle of high-dose mtx, but instead received rituxan and temodar, developed severe bradycardia on multiple blood pressure medications and elevated levels of phenytoin requiring transfer to the icu. . 1. bradycardia: pt developed a hr of 30-33 at 9am on [**9-16**]. she was also lethargic and hypothermic. her bp was stable around 90s-120s/50s-60s. an ekg showed bradycardia w/o block. a total of 2 mg atropin was given with only transient effect. she was put on telemetry. her bp meds were held. ivf 100cc/h were started for an elevated calcium and dehydration. her morning phenytoin level was 19.3 and phenytoin was held since then. cardiology was consulted and the icu was made aware of the patient. stat lytes, free phenytoin, tfts, lfts and a head ct were ordered. head ct was without any catastrophic event. soon after the ct, the patient's bp dropped, ivf and another 2 mg atropin were given without much effect. a dopamine drip was started and she was transferred to the unit. . in the icu, the patient's bp was supported with ivf as needed. she was monitored on tele and had atropine at the bedside. her hypothermia was concerning for sepsis and pt was initially broadly covered with abx, but then selectively treated with linezolid for a positive [**month/day (4) **] in the urine which was not treated before since thought to be a colonizer. her seizure prophylaxis was provided with keppra and dilantin was continued to be held. . the exact cause of bradycardia remains unclear. initially, thoguht to be an adverse reaction between diltiazem and dilantin, but dilantin would lower levels of diltiazem as a p450 activator. bradycardia, hypothermia and hypotension could also have been secondary to urosepsis (pos [**month/day (4) **] in urine), but even on appropriate coverage for [**name (ni) **], pt still had episodes of bradycardia and hypothermia. the third possible cause would have been involvement of hypothalamic structures by her cns lymphoma. however, imaging did not point towards this possibility either. . on the onc floor, the pt did well for 1 week, with heart rates mostly in the 50s-70s, though occasionally noted in the 40s. she continued to receive chemotherapy for her cns lymphoma. on [**9-26**], the patient was noted to have again a heart rate in the 30s. her bp was 143/59 and temp of 97. the pt wa given atropine x3 with some response in the heart rate, though remained bradycardic. dopamine drip was started on the onc floor and the pt was transferred to the [**hospital unit name 153**] for further monitoring. . during her second stay in the icu, a trial was started off dobutamine. the patient did well, maintaining sbps and uop despite a hr in the 30s. no further intervention was done and the patient remained asymptomatic despite bradycardia. cardiology and eps were consulted. it was decided that a permanent pacemaker is not indicated in this patient. wshe was retransferred to the oncology floor on [**10-1**]. . on retransfer to oncology floor on [**10-1**], the patient was normotensive, her hr was 46. she was alert, but tired and not oriented to time (which is her baseline). her dilantin, bb and ccb were continued to be held. she remained asymptomatic despite a hr in the 40s until discharge. . 2. hypothermia - pt was hypothermic during her bradycardic episodes. thought to be related to urosepsis with [**month/year (2) **]. cxr showed no signs of active pulmonary process. blood cx from [**9-16**] were negative. bcx from [**9-20**] and [**9-26**] were also negative as well as a ucx from [**9-27**]. pt completed an antibiotic course with linezolid. the hypothermia briefly resolved on transfer to the oncology floor. however, pt still had occasional hypothermic temperatures on the floor again. pt was asymptomatic on discharge. . 3. cns lymphoma - chemotherapy has been coordinated by dr. [**last name (stitle) 4253**]. mri of brain on [**9-11**] showed possible slight progression in left temporal lobe. initially it was planned to start the 6th cycle of high dose mtx. cards were consulted on [**9-9**] b/o previous cardiovascular problems with h.d. mtx. rec was to pretreat with diltiazem 60 mg [**hospital1 **] to reduce effects of diastolic dysfxn, if pt is going to rechallenged with mtx again. diltiazem was started and amlodipin d/c'ed instead. pt's urine was alkanalized and she was hydrated. however, due to tendency to get volume overloaded, it was decided not to give mtx, but to start instead chemo with rituxan and temodar which was given on [**9-13**]. temodar was continued daily and another dose of rituxan was given on [**9-21**]. temodar should be given qhs for 6 wks since treatment start. pt was continued on her outpatient dexamethasone. she was put on riss. she was also continued on her pcp prophylaxis for [**name9 (pre) 4820**] steroid use. pt consulted for reconditioning and gait. pt was stable on discharge and an outpatient appointment for the next dose of rituxan has been scheduled. . 4. seizure d/o - secondary to cns lymphoma. dilantin was held since bradycadic event. pt was kept on keppra since then. pt did not seize since having been retransferred to the oncology floor. pt was discharged on keppra. . 5. hypercalcemia - pt developed hypercalcemia prior to the bradycardic event. endocrine was consulted. etiology unclear but possibly due to primary hyperthyroidism since pth was elevated. pt received calcitonin during her hospital stay as well as lasix but ca was still 12.2 on [**9-23**] (after correction for albumin of 3.0). pt remained asymptomatic and was discharged with a stable, but slightly elevated calcium. an ionized calcium was 1.47. vit d25oh was within the normal range. it is recommended that her pcp follows up on the hypercalcemia. it is suggested to get a sestamibi scan to evaluate for parathyroid adenoma/hyperplasia, as well as a dexa scan since pt is on longstanding steroids. . 6. diastolic dysfunction - pt is known to have diastolic dysfunction in the past. cardiology was consulted during her hospital stay. b/o her bradycardic episode, bb and ccb were held since then. after stabilization in the unit and retransfer to the floor, she was started on hctz 25 qd on [**9-21**] and on captopril 6.25 tid on [**9-21**]. however, hctz was d/c'ed on [**9-23**] due to hypercalcemia. . pt was discharged on lisinopril 5 mg qd and captopril was d/c'ed, as recommended by cardiology. it is recommended that her pcp is going to follow up and titrate up on the lisinopril dose if bp and renal functions allows. . 7. hypothyroidism - continue synthroid, tfts were stable. . 8. agitation - stable mostly during her stay. haldol has occasionally been used to calm her down but it was tried to avoid haldol. pt required 1:1 sitter on most nights to prevent patient from pulling out lines. pt was without sitter over 24h prior discharge. . 9. anemia - baseline hct 28-32. iron studies c/w acd, given high ferritin, low tibc. normal folate, b12. monitored hct daily. follow up is recommended as an outpatient. . 10. f/e/n - cardiac/dm diet as tolerated, lytes were repleted as needed. . 11. ppx - heparin, ppi, bowel regimen, mouth care, oral nystatin for thrush . 12. comm - with sister hcp [**name (ni) **] [**name (ni) 99693**] [**telephone/fax (1) 99411**] . 13. access - right chemo port placed [**2201-9-11**]. piv. . 14. code - full medications on admission: 1. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 2. docusate sodium 100 mg capsule sig: two (2) capsule po tid (3 times a day). 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 4. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid (4 times a day). 5. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 6. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. multivitamin capsule sig: one (1) cap po daily (daily). 8. oxcarbazepine 600 mg tablet sig: one (1) tablet po bid (2 times a day). 9. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 10. olanzapine 10 mg tablet sig: one (1) tablet po twice a day. 11. phenytoin sodium extended 100 mg capsule sig: two (2) capsule po tid. 12. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po daily (daily). 13. dexamethasone 4 mg tablet sig: one (1) tablet po q12h (every 12 hours). 14. multivitamin capsule sig: one (1) cap po daily (daily). 15. miconazole nitrate 2 % powder sig: one (1) appl topical prn (as needed). 16. labetalol 100 mg tablet sig: 1.25 tablets po tid (3 times a day). 17. ativan 1 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for agitation. 18. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 19. haloperidol 2 mg tablet sig: 1-2 tablets po tid (3 times a day) as needed for severe agitation. 20. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 21. isosorbide mononitrate 30 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). 22. quinine sulfate 325 mg capsule sig: one (1) capsule po hs (at bedtime) as needed for leg cramps. 23. oxycodone 5 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain: for severe pain. try tylenol first. hold for oversedation or rr<12. 24. lisinopril 40 mg tablet sig: one (1) tablet po once a day. 25. lipitor 20 mg tablet sig: one (1) tablet po once a day. 26. aspirin 81 mg tablet sig: one (1) tablet po once a day. 27. lasix 40 mg tablet sig: one (1) tablet po twice a day: if weight increases by 3 lbs, increase to 60 [**hospital1 **] until wt normalizes. 28. albuterol sulfate 0.083 % solution sig: one (1) inhalation q4h (every 4 hours) as needed. 29. lactulose 10 g packet sig: one (1) po every 4-6 hours as needed for constipation. 30. sucralfate 1 g tablet sig: one (1) tablet po qid (4 times a day). . meds on retransfer to oncology from icu: - acetaminophen 325-650 mg po q4-6h:prn pain, fever - levetiracetam 500 mg po qam - albuterol 0.083% neb soln 1 neb ih q6h:prn wheezing - linezolid 600 mg iv q12h - aspirin 81 mg po daily - miconazole powder 2% 1 appl tp qid:prn groins, bottoms - atorvastatin 20 mg po daily - multivitamins 1 cap po daily - atropine sulfate 1 mg iv asdir at bedside - nystatin oral suspension 10 ml po qid - dexamethasone 4 mg iv q12h - senna 1 tab po bid:prn constipation - docusate sodium 100 mg po bid - sulfameth/trimethoprim ss 1 tab po daily - heparin 5000 unit sc tid - sucralfate 1 gm po qid - temozolomide 100 mg po hs - insulin sc (per insulin flowsheet) sliding scale - temozolomide 60 mg po hs - ipratropium bromide neb 1 neb ih q6h - thiamine hcl 100 mg iv daily - lactulose 30 ml po q8h:prn constipation discharge medications: 1. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed for pain, fever. 2. docusate sodium 100 mg tablet sig: one (1) tablet po bid (2 times a day). 3. nystatin 100,000 unit/ml suspension sig: ten (10) ml po qid (4 times a day). 4. multivitamins tablet, chewable sig: one (1) cap po daily (daily). 5. bactrim 400-80 mg tablet sig: one (1) tablet po once a day. 6. miconazole nitrate 2 % powder sig: one (1) appl topical qid (4 times a day) as needed for groins, bottoms. 7. atorvastatin 20 mg tablet sig: one (1) tablet po daily (daily). 8. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 9. albuterol 90 mcg/actuation aerosol sig: one (1) inhalation q4-6h prn as needed for shortness of breath or wheezing. 10. sucralfate 1 g tablet sig: one (1) tablet po qid (4 times a day). 11. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 12. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 13. ipratropium bromide 18 mcg/actuation aerosol sig: one (1) inhalation q4-6h prn as needed for shortness of breath or wheezing. 14. heparin flush port (10units/ml) 2 ml iv daily:prn flush portacath ports flush with 10 cc ns, then flush with 2 cc (10 u/cc) heparin (20 units heparin). each lumen daily and prn. inspect site every shift. 15. prochlorperazine 10 mg tablet sig: one (1) tablet po q6h prn as needed for nausea. 16. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 17. insulin regular human 100 unit/ml solution sig: as directed injection asdir (as directed). 18. temozolomide 100 mg capsule sig: one (1) capsule po hs (at bedtime) for 5 weeks: to complete 6 wk course. start date was [**9-19**]. please contact [**name (ni) 13291**] [**last name (namepattern1) 28272**] ([**hospital1 18**] pharmacy) for questions. 19. temozolomide 20 mg capsule sig: three (3) capsule po hs (at bedtime) for 5 weeks: to complete 6 week course. start date was [**9-19**]. please contact [**name (ni) 13291**] [**name (ni) 28272**] for questions. 20. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 21. levetiracetam 250 mg tablet sig: three (3) tablet po bid (2 times a day). 22. olanzapine 10 mg tablet sig: one (1) tablet po hs (at bedtime). 23. haloperidol 1 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for agitation. disp:*0 tablet(s)* refills:*0* 24. calcitonin (salmon) 200 unit/ml solution sig: two (2) units injection daily (daily): please give only if calcium is greater than 11. please check calcium twice weekly. disp:*qs u/ml* refills:*2* 25. decadron 0.75 mg tablet sig: four (4) tablet po once a day. 26. outpatient lab work please check calcium levels twice weekly. please give calcitonin as prescribed if calcium greater than 11. discharge disposition: extended care facility: [**hospital3 2558**] - [**location (un) **] discharge diagnosis: primary diagnosis: 1. cns lymphoma 2. bradycardia 3. hypothermia secondary diagnosis: 1. hypercalcemia 2. hypothyroidism discharge condition: afebrile. hemodynamically stable. tolerating po. discharge instructions: please call your primary doctor or return to the ed with fever, chills, chest pain, shortness of breath, fainting, unvoluntary movement of body parts, loss of conscienceness or any other concerning symptoms. please take all your medications as directed. please keep you follow up [**location (un) 4314**] as below. followup instructions: please follow up with your primary care doctor ([**last name (lf) **],[**first name3 (lf) 569**] e. [**telephone/fax (1) 250**]) on [**2201-10-21**] at 10.40am, [**hospital ward name 23**] 6th south suite. he will decide if your blood pressure is stable enough to restart your blood pressure medications. . you are also scheduled to get a so called sestamibi scan on [**2201-10-21**] at 1300. the test takes up to three hours. it takes placae on the [**location (un) **] [**hospital ward name 2104**] bldg, [**hospital ward name **] (phone: ([**telephone/fax (1) 9596**]). once the results have been obtained, you should be seen by endocrinologist dr. [**last name (stitle) **] (phone number: ([**telephone/fax (1) 23805**]) on [**2201-11-2**] at 15.30. . please also follow up with your cardiologist dr. [**last name (stitle) 7965**] (phone ([**telephone/fax (1) 12468**]) on [**12-2**]. . provider: [**first name4 (namepattern1) 8990**] [**last name (namepattern1) **], md phone:[**telephone/fax (1) 1803**] date/time:[**2202-3-19**] 2:00 . please follow up with dr. [**last name (stitle) **],hem/onc hematology/oncology-cc9 on [**2201-10-16**] at 11am. her office will contact you regarding the exact appointment for an mri of your brain. please call [**telephone/fax (1) 1844**] with any questions.",1
91,"admission date: [**2120-11-19**] discharge date: [**2094-2-8**] date of birth: [**2044-8-23**] sex: f service: [**doctor last name 1181**] medicine chief complaint: shortness of breath and dyspnea. history of present illness: the patient is a 76-year-old woman who was recently discharged from the [**hospital1 346**], where she was evaluated for multiple medical problems listed separately in the past medical history, who was transferred from [**location (un) 2716**] point because of increasing dyspnea, shortness of breath, and cough for one day. the patient has chronic fevers. she denied a battery of constitutional symptoms including headache, fever, chills, nausea, vomiting, diarrhea, dysuria. past medical history: 1. breast cancer metastatic to [**location (un) 500**] and spleen. 2. fever of unknown origin likely due to malignancy or adrenal insufficiency. 3. left lower lobe collapse. 4. congestive heart failure with diastolic dysfunction and preserved ejection fraction. 5. atrial fibrillation. 6. adrenal insufficiency status post bilateral adrenalectomy. 7. melanoma status post excisional biopsy. 8. meningioma status post resection. 9. thyroid nodules of unclear origin. 10. inappropriate antidiuretic hormone release previously. 11. external hemorrhoids. allergies: opiates of unclear reaction as well as to tape, where she develops a rash. medications on presentation: 1. mirtazapine 50 mg in the evening. 2. tranxene 7.5 mg daily. 3. lorazepam 0.25 mg daily. 4. colace 100 mg twice daily. 5. fludrocortisone 0.1 mg daily. 6. hydrocortisone 30 mg in the morning and 20 mg in the evening. 7. pantoprazole 40 mg daily. 8. arimidex 4 mg daily. 9. metoprolol 62.5 mg daily. physical examination on presentation: vital signs: temperature 98.4, heart rate 101 and irregular, blood pressure of 164/67, and oxygen saturation is 89% on room air, and 98% on 4 liters nasal cannula. general: this is a chronically ill appearing elderly-pale woman, who did not cooperate with the entire examination. heent: normocephalic. there is a well-healed scar from her meningeal resection, she has anicteric sclerae and pale conjunctivae. pupils are equal, round, and reactive to light. extraocular movements are intact without nystagmus. the throat was clear. neck: supple, thyroid not palpable, the jugular veins are flat. there is no carotid bruit. nodes: there is no cervical, supraclavicular, axillary, or inguinal adenopathy. lungs: she had poor effort, decreased excursion, and decreased breath sounds at the based. she had slight wheezing and crackles diffusely. heart: irregular, tachycardic, normal s1, s2, no extra sounds. abdomen: she had normal bowel sounds, soft, nontender, and nondistended. spleen tip was palpable. the liver was not palpable. extremities: the patient had +2 lower extremity edema to her mid calf. vascular: the radial, carotid, and dorsalis pedis pulses were +2 bilaterally. laboratory evaluation on presentation: white blood cell count 47.4, hematocrit 26.0, platelets 209. chemistry panel was normal. electrocardiogram revealed multifocal atrial tachycardia at 95 beats per minute, there was no interval change from a previous electrocardiograms. hospital course: 1. cardiac: over the course of the patient's long hospital stay, her dose of metoprolol was sequentially increased from 62.5 mg twice daily to ultimately 75 mg every eight hours for rate control. in consultation with the cardiology service, the patient was also given an ace inhibitor. she required periodic diuresis with furosemide, approximately every four days she received furosemide for volume overload. her heart rate and blood pressure were well controlled on this regimen. patient underwent repeat surface echocardiography which revealed increased pulmonary hypertension, unchanged ejection fraction. 2. endocrine: the patient's requirement for hydrocortisone replacement fluctuated during the course of the hospital stay in consultation with the endocrine service, an attempt was made to lower her hydrocortisone replacement, however, her white blood cell count climbed to over 70 when decreasing the dose of hydrocortisone to 25 mg every 12 hours. she ultimately required several stress doses up to 100 mg every eight hours. her fingersticks were always within the normal range despite several conventional serum glucose values below 40, this was attributed to pseudohypoglycemia caused by high white blood cell count. the patient underwent ultrasonography of the thyroid gland, which revealed nodules unchanged from previous evaluation. given the multiple comorbidities of this patient, the endocrine service did not recommend further evaluation at this time. 3. psychiatric: the patient had several episodes of confusion, paranoid delusions, and visual hallucinations. in consultation with the psychiatric service, she was given a trial of risperidone, however, the patient was overly sedated on this medication, and was eventually withdrawn. the patient underwent further computer tomography of the head revealing no new mass lesions during two or three episodes of unresponsiveness. 4. hematology: as reviewed in previous summary, the patient is now transfusion dependent. he received a transfusion of [**12-12**] pack units approximately every 3-4 days while in the hospital to maintain a hematocrit of approximately 38%. she also required periodic diuresis with blood transfusions, no fevers or adverse reactions occurred during transfusion. 5. oncology: as reviewed in previous summaries, the patient underwent [**month/day (2) 500**] marrow biopsy on her last admission. her cytogenetic evaluation revealed possible early myelodysplastic syndrome or aml given that there were two cells bearing the lesion that .................... chromosome. the oncology service was consulted, and they deemed that the patient does not have either myelodysplastic syndrome or aml. the patient underwent splenic biopsy in the interventional radiology suite twice. the first time the pathology specimen revealed collection of megakaryocytes, though was not diagnostic. the second time, a large amount of necrotic debris, macrophages was recovered as well as neutrophils. this was deemed to be consistent with infection. 6. infectious disease: patient's fevers over the first half of her hospital course abated, however, she did have persistent white blood cell elevation attributed to malignancy and adrenal insufficiency. her large left pleural effusion as well as her cerebrospinal fluids were sampled, neither which shown to have an infection. however, on [**2120-12-17**], the patient became hypotensive. urinalysis revealed enterococcal urinary tract infection. she was transferred to the intensive care unit for sepsis. she was placed on vancomycin intravenously. after two days, her blood pressure stabilized, and she was returned to the general medical floor. the remainder of this hospital summary will be dictated separately. [**first name11 (name pattern1) **] [**last name (namepattern1) 1211**], m.d. [**md number(1) 1212**] dictated by:[**last name (namepattern4) 96234**] medquist36 d: [**2120-12-19**] 11:04 t: [**2120-12-19**] 11:03 job#: [**job number **]",0
92,"admission date: [**2107-7-18**] discharge date: [**2107-8-10**] date of birth: [**2033-4-27**] sex: f service: medicine allergies: risperdal / ace inhibitors attending:[**first name3 (lf) 29767**] chief complaint: flacid paralysis of lower extremities major surgical or invasive procedure: 1. t8-l2 fusion. 2. multiple thoracic laminotomies. 3. laminectomy of l1. 4. segmental instrumentation, t8-l2. 5. right iliac crest autograft. 6. anterior decompression 7. posterior decompression 8. t11/l1 fusion 9. peg tube placement 10. picc line placement history of present illness: 74f with hx of dementia, schizophrenia and recent t12 compression fx who presented to [**hospital1 18**] on [**7-18**] with placcid paralysis and found to have cord compression. per notes, pt fell on [**6-19**] and since then has had persistent back pain and refuses to move leg. patient was reportedly ambulating with cane prior to fall. lumbarsacral spine and pelvis xray at that point was negative for fracture. patient then noted to have decreased hct and na. given long history of smoking, ct chest done on [**7-13**] for malignancy workup. it showed nonpathologic compression t12 fracture. it also showed rll consolidation for which she completed treatment of levaquin for 7 d. on day of admission, pt presented with flaccid paralysis. mr t spine show severe t12 compression fracture with retropulsed fragment causing severe canal stenosis, concerning for cord compression. patient recieved steroids in ed and was admitted to the medicine service. past medical history: dementia schizophrenia history of chronic gi bleed and refused gi workup in the past anemia gerd copd (last pft in [**2095**]: fev1/fvc of 73, fev1 71% of predicted) hypertension benign neoplasm of colon diabetes mellitus osteoarthritis neuropathy, urinary incontinence social history: ms. [**known lastname 7168**] is a nursing home resident. she worked in the past as a secretary. she is a smoker up to two packs per day. rare alcohol use. family history: there is one sibling with schizophrenia. physical exam: temp 98, bp 151/77, hr 106, r 33, o2 97% on nrb gen: elderly female in moderate resp distress, grunting occasionally, using some accessory muscles heent: mm dry, eomi, pupils dilated, reactive to light cv: heart sounds not heard [**2-10**] rhoncherous breath souds chest: no crackles at bases, exp wheezes bilaterally; chest tube in left side abd: hypoactive bowel sounds, nontender, soft sacrum: small 2cm area of erythema ext: 2+ dp, no edema neuro: ao x 2 (not to place), cn 2-12 intact, 4+/5 strength in upper ext, won't move lower ext; ? decreased sensation in lower ext; 1+ dtrs in lower ext, 2+ dtrs in upper ext; babinski neither up nor downgoing pertinent results: cxr: persistent left retrocardiac opacity and left pleural effusion. . echo on [**2107-7-19**]: the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy with normal cavity size. regional left ventricular wall motion is normal. left ventricular systolic function is hyperdynamic (ef>75%). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the left ventricular inflow pattern suggests impaired relaxation. transmitral doppler and tissue velocity imaging are consistent with grade i (mild) left ventricular diastolic dysfunction. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. . mr l spine scan [**2107-7-17**] compression fracture at t12 with severe canal compromise. this is incompletely imaged on this examination and the thoracic spine mr should be obtained. distended bladder could be due to cord compression. . mr contrast gadolin [**2107-7-18**] compression of the t12 vertebral body with large retropulsed osseous fragment resulting in marked cord compression and cord edema at the level of compression and in the conus. there are some features of the compression which raise the possibility of this being a pathologic fracture rather than a simple insufficiency fracture. . chest (portable ap) [**2107-7-19**] 10:48 pm the endotracheal tube previously in the right main bronchus has been repositioned to standard placement at the level of the sternal notch and, accordingly, the previously collapsed left lung has reexpanded. a pleural tube projects over the base of the left chest. there is no pneumothorax or appreciable pleural effusion. heart is top normal size. there is engorgement of hilar and pulmonary vasculature suggesting borderline cardiac dysfunction or volume overload. tip of the left subclavian catheter projects over the upper svc. nasogastric tube ends in the stomach. . chest port. line placement [**2107-7-19**] 9:45 pm total collapse of the left lung secondary to et tube tip in the right main bronchus. right basal consolidation. small left basilar pneumothorax. left subclavian line tip in the svc. . t12 vertebral body r/o tumor pathology: bone with focal necrosis, reactive changes, intramedullary fat necrosis and granulation tissue consistent with healing fracture. hyaline cartilage. no osteomyelitis seen. no evidence of malignancy. . bilat lower ext veins port [**2107-7-21**] 1:28 am bilateral lower extremity venous ultrasound: [**doctor last name **] scale and doppler son[**name (ni) 1417**] of the bilateral common femoral, superficial femoral and popliteal veins were performed. these demonstrate normal compressibility, flow, augmentation, and waveforms. no intraluminal thrombus identified. impression: no evidence of bilateral lower extremity dvt. . ekg [**2107-8-7**]: baseline artifact. rhythm is most likely sinus tachycardia. st segment elevation in leads vi-v2. q waves in leads vi-v3. findings suggest anteroseptal myocardial infarction/injury of undetermined age. there are also lateral st segment depressions suggestive of myocardial ischemia. clinical correlation is suggested. compared to the previous tracing of 7 14-06 anterior and anterolateral abnormalities persist. . echo [**2107-8-9**]: the left atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (lvef>55%), without regional wall motion abnormalities. tissue velocity imaging e/e' is elevated (>15) suggesting increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild to moderate ([**1-10**]+) aortic regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. impression: symmetric lvh with preserved global and regional biventricular systolic function. mild-to-moderate aortic regurgitation. compared with the prior study (images reviewed) of [**2107-7-19**], the findings appear similar. labs: [**2107-8-10**] 06:00am blood wbc-9.8 rbc-3.06* hgb-9.3* hct-26.3* mcv-86 mch-30.4 mchc-35.3* rdw-19.0* plt ct-359 [**2107-7-18**] 02:00pm blood wbc-11.4*# rbc-4.43 hgb-11.4*# hct-34.0* mcv-77*# mch-25.7*# mchc-33.5# rdw-16.8* plt ct-623*# [**2107-8-9**] 05:20am blood neuts-85.6* lymphs-6.3* monos-2.6 eos-5.4* baso-0.2 [**2107-7-18**] 02:00pm blood neuts-79.7* lymphs-12.0* monos-5.4 eos-1.9 baso-1.0 [**2107-8-9**] 05:20am blood anisocy-2+ macrocy-1+ microcy-1+ [**2107-8-10**] 06:00am blood plt ct-359 [**2107-8-10**] 06:00am blood pt-12.5 ptt-24.3 inr(pt)-1.1 [**2107-8-4**] 05:50am blood pt-14.9* ptt-26.1 inr(pt)-1.3* [**2107-7-18**] 02:00pm blood pt-13.2* ptt-24.0 inr(pt)-1.2* [**2107-8-10**] 06:00am blood glucose-97 urean-16 creat-0.4 na-135 k-4.1 cl-97 hco3-27 angap-15 [**2107-7-18**] 02:00pm blood glucose-119* urean-28* creat-1.0 na-136 k-4.7 cl-97 hco3-27 angap-17 [**2107-8-10**] 06:00am blood alt-43* ast-31 ld(ldh)-374* alkphos-158* amylase-34 totbili-0.7 [**2107-8-7**] 04:38pm blood ck-mb-notdone ctropnt-0.10* [**2107-7-22**] 01:11am blood ck-mb-19* mb indx-4.3 ctropnt-0.18* [**2107-8-10**] 06:00am blood albumin-2.6* calcium-8.3* phos-3.9 mg-1.9 [**2107-8-9**] 05:20am blood albumin-2.5* calcium-7.8* phos-3.7 mg-1.7 [**2107-8-9**] 05:55pm blood vanco-19.0* [**2107-7-27**] 07:15am blood vanco-13.9* [**2107-7-29**] 06:06am blood type-art po2-126* pco2-43 ph-7.43 caltco2-29 base xs-4 [**2107-7-29**] 06:06am blood freeca-1.19 [**2107-8-10**] 06:00am blood vitamin d 25 hydroxy-pnd brief hospital course: on [**7-19**], pt was taken to or by ortho spine for a thoracotomy with t12 vertebrectomy with t11-l1 fusion with plans to take her back on [**7-22**] for posterior approach. during the operation, pt had left lung collapse requiring a chest tube. at this point, she was started on levo/flagyl. during her stay, pt was noted to have occasional episodes of tachypnea, tachycardic to the 110s and hypertensive to the 190s. she responded well to hydralazine and morphine. lenis were done to rule out dvt and were negative. on day of transfer to icu, pt was found to have a hr in the 120s, rr in the 40s, satting 85% on 50% face mask --> 94% on nrb. (during her stay, she had been 91% on ra --> 99% on 50% face mask.) she was given lasix 20mg iv x 1 and improved somewhat symptomatically. two houws later, she again was found in resp distress and was given 20mg more of lasix. she had put out 1.3l in response to the two boluses of lasix and her saturations had improved to 97% on nrb with a decrease in her resp rate. she was then transferred to the icu for closer monitoring of her resp distress. . initially in icu, pt appeared more comfortable, satting 97-99% on nrb with rr in the mid 20s. she was given 1"" of nitropaste and 1mg of morphine to help with agitation. thirty minutes after her arrival to icu, she had another episode of respiratory distress. however, now, pt was noted to have inspiratory stridor asociated with rr to the 40s, diaphoresis and tachycardia. also, of note, the submental area of her neck appeared to be swollen but unclear what her baseline is. she was emergently intubated using fiberoptic bronchoscopy given her difficult airway. on bronchoscopy, she was noted to have a very small airway with diffuse swelling and copious secretions. she was intubated successfully and her heart rate improved to the 80s. her bp also dropped into the 50s so she was started on neosynephrine. . the remainder of her hospital course was complicated by the following issues: . 1) resp distress: in consideration of stridor which precipitated previous respiratory failure, it is possible that pt had laryngeal edema from prior intubation (during first surgery). then she also had either pneumonia or diastolic heart failure (or both) that caused some resp distress. her resp distress may have then exacerbated her pre-existing edema. in addition, the increased negative pressure from her resp distress through a narrowed airway may have caused some pulm edema. patient was intubated for resp. distress and found to have laryngeal edema during intubation. neck ct [**7-23**] showed some edema of laryngeal soft tissues around ett. no new medications were on board; however it was considered that this may have been angioedema from acei. her ace-i was thus discontinued. pt was extubated successfully on [**7-26**]. sputum from [**7-22**] grew out mrsa, now s/p 10 day course of vancomycin. cxr during episode of desaturation on [**8-7**] reveals worsening pulmonary edema. ace inhibitor was held due to questionable adverse reaction in context of respiratory difficulty. patient was diuresed to maintain negative fluid balance and urine output was adequate. she did not have further episodes of desats and remained stable on room air. patient produced adequate secretions with deep suctioning and sputum gram stain was negative and preliminary culture had no growth. she was taken off contact precautions since she was not actively infected with mrsa. she received muciprocin x 5 days [**hospital1 **] for mrsa positive nasal swab. . 2) t12 compression fracture with cord compression: patient was status post anterior and posterior decompression surgeries, performed by dr [**last name (stitle) 363**]. the chest tube from prior surgery was removed and a drain was placed. steroids were discontinued on [**7-27**]. drain was removed [**7-28**]. patient continued to remain paralyzed in her bilat les. cultures taken of wound during or proceedings negative for organisms. pain control with iv morphine, tylenol was adequate. . 3) hypertension: necessary to control pain in order to control bp. bp stabilized, back on bb, holding acei. . 4) diastolic heart failure: on recent echo ([**7-19**]), ef hyperdynamic with evidence of diastolic heart failure. beta blocker was resumed once bp was stable. patient has had slightly elevated cardiac enzymes likely from chronic left ventricular strain in context of chf. decision was made not to heparinize since ekg did not reveal st changes lowering concern for infarct. patient had a repeat echo on [**8-9**] to evaluate for worsening chf given pulmonary edema and revealed ef 55% with similar findings to prior study. . 5) anemia: baseline hct in low 30's ([**2102**] is last documented), now in mid 20's but stable; she was transfused 1 unit prbcs on [**8-7**] due to low hct and it remained around 27. patient had hemolysis workup with haptoglobin, ldh, and t bili which were all within normal limits. she was guiaic negative. . 6) schizophrenia- haldol im q month, remeron, zyprexa, and trazodone 50 mg qhs. patient had episodes of sun-downing as she was disoriented in the evenings to self and time. it was not clear whether this was her baseline mental status. lfts were checked to evaluate delirium and showed mild elevation in alt. patient's lipitor dose was decreased by half. . 7) diabetes mellitus: very low insulin need; continue riss . 8) hoarseness: patient with new hoarseness s/p extubation, now improving. per ent consult, continue ppi and she will need to be scheduled for outpatient follow-up. . 10) fen: patient failed s&s on [**8-1**] and subsequently removed her own ngt. she was at that time without nutrition source. gi placed peg on [**8-4**] and tolerated tube feeds well with no evidence of aspiration on deep suctioning. patient was started on calcitonin for regulation of pth's activity on bone resorption. levels of pth and vitamin oh-d were pending on discharge and will be followed up by pcp. . 11) healthcare proxy: patient is not competent with baseline dementia and psychiatric condition. healthcare proxy and legal guardian is [**name (ni) **] [**name (ni) 68736**], ([**telephone/fax (1) 98705**] at advoguard, inc. pcp [**last name (namepattern4) **]. [**last name (stitle) 1699**] has been in touch with guardian regarding treatment goals and code status. . 12) dispo: continue pt. she will be discharged to [**hospital1 1501**]. . 12) code status - full code. medications on admission: * levofloxacin 500 mg iv q24h * metronidazole 500 mg iv q8h * lisinopril 20 mg * atenolol 100 mg po daily * insulinss * ipratropium bromide neb 1 neb ih q6h * albuterol 0.083% neb soln 1 neb ih q4-6h:prn * fluticasone propionate 110mcg 2 puff ih [**hospital1 **] * acetaminophen (liquid) 650 mg ng q6h * miconazole powder 2% 1 appl tp tid:prn * mirtazapine 30 mg po hs * benztropine mesylate 1 mg po bid * dexamethasone 4 mg iv q6h * morphine sulfate 1-2 mg iv q4h * docusate sodium 100 mg po bid * multivitamins 1 cap po daily * famotidine 20 mg iv q12h * nicotine patch 14 mg td daily * guaifenesin 15 ml ng q4h * heparin 5000 unit sc tid discharge medications: 1. therapeutic multivitamin liquid sig: one (1) cap po daily (daily). 2. benztropine 1 mg tablet sig: one (1) tablet po bid (2 times a day). 3. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation [**hospital1 **] (2 times a day). 4. olanzapine 2.5 mg tablet sig: three (3) tablet po daily (daily). 5. mirtazapine 15 mg tablet sig: two (2) tablet po hs (at bedtime). 6. insulin lispro (human) 100 unit/ml solution sig: one (1) ssi subcutaneous asdir (as directed). 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 8. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed. 9. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 10. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day). 11. nicotine 14 mg/24 hr patch 24hr sig: one (1) patch 24hr transdermal daily (daily). 12. lactulose 10 g/15 ml syrup sig: thirty (30) ml po tid (3 times a day). 13. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 14. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). 15. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours). 16. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 17. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 18. calcitonin (salmon) 200 unit/actuation aerosol, spray sig: one (1) nasal daily (daily). 19. haldol decanoate 50 mg/ml solution sig: one (1) 1 intramuscular once a day as needed for agitation. 20. ativan 0.5 mg tablet sig: one (1) tablet po every 4-6 hours as needed for anxiety. 21. morphine 30 mg tablet sustained release sig: one (1) tablet sustained release po every 4-6 hours as needed for pain. discharge disposition: extended care facility: [**hospital1 2670**] - [**location (un) **] discharge diagnosis: main diagnosis: t12 burst fracture and paraplegia s/p t8-l2 fusion on [**2107-7-26**] respiratory distress other diagnosis: dementia schizophrenia history of chronic gi bleed and refused gi workup in the past anemia gerd copd (last pft in [**2095**]: fev1/fvc of 73, fev1 71% of predicted) hypertension benign neoplasm of colon diabetes mellitus osteoarthritis neuropathy, urinary incontinence discharge condition: fair. discharge instructions: please take all medications. followup instructions: pcp [**last name (namepattern4) **]. [**last name (stitle) 1699**] for further management. . pt has an ortho appointment with dr. [**last name (stitle) 363**] ([**telephone/fax (1) 3573**]) at 10:30 on [**8-24**], [**hospital ward name 23**] 2 orthopedics, and will require transportation for this.",1
93,"admission date: [**2104-3-2**] discharge date: [**2104-3-3**] date of birth: [**2053-8-1**] sex: f service: medicine allergies: ciprofloxacin / erythromycin base / zyprexa attending:[**first name3 (lf) 2751**] chief complaint: altered mental status major surgical or invasive procedure: none history of present illness: 36 yo f w/ pmh of hypothyroid, headaches and depression presented with ams. she was staying with a friend and said she wanted a bottle [**last name (lf) **], [**first name3 (lf) **] friend went to buy [**company 19015**], called her from store to ask if cans were okay, but when she came back 5 minutes later, she found pt lethargic and not quite responsive, slurred speech. this was all within 30 minutes of her taking her am medicaitons. there were no pill bottles found nearby. the friend called patients' husband who confirmed abnormal mental status, so then she called 911, and patient was found to be hypotensive in the 80s and brady in the 40s. the night previously she had taken benadryl, but denies taking tizanidine which she toook until recently for pain syndrome. she is on an atypical very high dose pain regimen of several medications. . on presentation to the ed her temp was 96.9 but then dipped to 95.2 prior to transfer to the floor so she was admitted to the icu. vs prior to transfer: 95.2 rectal, 55, 104/62, 15, 96% 2l nc. ekg sinus brady w/ normal intervals. got 8l ns and had put out 300cc urine/5hrs. bp improved to 104/62 but was noted to be hypothermic so admitted to icu, got 10mg decadron for adrenal insufficiency. has history of suicide attempts by report from ed (but patuient denies), and her son died recently. . she denies any suicidal ideation or taking extra medications. she says she took her am clonazepam 2mg, gabapentin 1600mg, mexilitine 250mg and wellbutrin 300mg and that her friend left her at home in a normal condition and returned 10 minutes later to find her unresponsive. she denies illicits and alcohol. denies any beta-blockers, ccbs or antihypertensives. past medical history: chronic migraine headaches, seen at [**hospital 90425**] clinic since [**2097**] hypothyroidism depression - no history of suicide per patient and her husband generalized anxiety disorder recent removal of occipital nerve stimulator 3 wks ago laminectomy cad: mi s/p stent [**2101**] (no betablocker due to bradycardia) chronic neck pain social history: married, lives in nj, is here visiting friend [**doctor first name **]. no tobacco, rare alcohol, no illicits, denies amphetamines specifically (because urine tox screen was amphetamine positive). son [**name (ni) **] died [**2103-8-12**] of cancer after battling aggressive lung cancer x 2 years at age of 21. has a 23 yo daughter. lives with husband in [**name2 (ni) **] [**name (ni) 760**]. family history: son with alveolar rhabdomyosarcoma, father with pacemaker. physical exam: admission physical exam: vs: temp: 98f bp: 115/86 hr: 57 rr: 15 o2sat 94% ra gen: pleasant, comfortable, nad, tearful heent: perrl, eomi, anicteric, mmm, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules resp: crackles in bases bilaterally, no wheezes cv: rr, s1 and s2 wnl, no m/r/g abd: nd, +b/s, soft, nt, no masses or hepatosplenomegaly ext: no c/c/e skin: no rashes/no jaundice/no splinters neuro: aaox3, [**doctor last name 1841**] in reverse, able to spell world backwards. cn ii-xii intact. 5/5 strength throughout. no sensory deficits to light touch appreciated. rectal: normal tone, brown stool discharge: vss anicteric, op clear, neck supple lungs cta bilat cor: rrr no mrg abd: soft nt/nd ext: no edema skin: lumbar, cervical and flank scars from stimulator (and its battery) removal 3 weeks ago, c/d/i. neruo: a&o x 3, non-focal pertinent results: [**2104-3-2**] ct head there is no evidence of infarction, hemorrhage, mass effect, or extra-axial collection. the ventricles and sulci are normal in size and configuration. the [**doctor last name 352**]-matter/white-matter differentiation is preserved throughout. the orbits appear normal. the mastoid air cells are clear. there is a high-riding left jugular bulb. the visualized portions of the paranasal sinuses are clear. impression: normal study. . [**2104-3-2**] cxr no definite evidence of pneumonia. mild edema noted suggesting volume overload. when clinically feasible, consider pa and lateral radiographs of the chest for further evaluation. . admission labs: [**2104-3-2**] 10:30am wbc-3.1* rbc-3.53* hgb-10.5* hct-31.2* mcv-88 mch-29.8 mchc-33.8 rdw-12.8 [**2104-3-2**] 10:30am neuts-48.7* lymphs-38.4 monos-7.3 eos-4.1* basos-1.5 [**2104-3-2**] 10:30am pt-12.9 ptt-24.1 inr(pt)-1.1 [**2104-3-2**] 10:30am asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg [**2104-3-2**] 10:30am cortisol-7.8 [**2104-3-2**] 10:30am tsh-8.6* [**2104-3-2**] 10:30am caltibc-330 vit b12-370 folate-16.1 ferritin-15 trf-254 [**2104-3-2**] 10:30am ctropnt-<0.01 [**2104-3-2**] 10:30am lipase-39 [**2104-3-2**] 10:30am alt(sgpt)-143* ast(sgot)-118* ld(ldh)-347* alk phos-39 tot bili-0.2 [**2104-3-2**] 10:30am glucose-129* urea n-15 creat-0.7 sodium-136 potassium-5.2* chloride-104 total co2-27 anion gap-10 [**2104-3-2**] 10:36am urine blood-neg nitrite-neg protein-25 glucose-neg ketone-neg bilirubin-mod urobilngn-neg ph-7.0 leuk-neg [**2104-3-2**] 10:36am urine rbc-0 wbc-0-2 bacteria-occ yeast-none epi-<1 [**2104-3-2**] 10:36am urine bnzodzpn-pos barbitrt-neg opiates-neg cocaine-neg amphetmn-pos mthdone-neg . discharge labs: [**2104-3-3**] 05:00am blood wbc-4.5# rbc-3.63* hgb-10.6* hct-31.6* mcv-87 mch-29.3 mchc-33.7 rdw-12.4 plt ct-228 [**2104-3-3**] 05:00am blood glucose-92 urean-9 creat-0.5 na-142 k-3.6 cl-112* hco3-22 angap-12 [**2104-3-3**] 05:00am blood alt-371* ast-253* alkphos-66 totbili-0.3 [**2104-3-3**] 05:00am blood albumin-3.6 calcium-8.0* phos-3.0 mg-1.7 [**2104-3-2**] 11:47pm blood alt-492* ast-427* ld(ldh)-400* ck(cpk)-60 alkphos-75 totbili-0.2 [**2104-3-3**] 05:00am blood alt-371* ast-253* alkphos-66 totbili-0.3 [**2104-3-2**] 11:47pm blood hbsag-negative hbsab-negative hbcab-negative hav ab-positive [**2104-3-2**] 11:47pm blood hcv ab-negative [**2104-3-2**] 10:30am blood caltibc-330 vitb12-370 folate-16.1 ferritn-15 trf-254 brief hospital course: icu course: # hypothermia: the patient had a temperature in the ed of 95.2f. likely not sepsis, given hr 55 and no localizing source. cxr, u/a negative. wbc 3.1 and hypotension could, however, suggest sepsis. likely secondary to 8l ns at room temperature. given a 70kg female with about 31.5l total body water where q=mc(deltat) and room temperature saline being 23c, (excluding the heat content of other tissues which is not significant) one would expect the temperature of her tbw to be 34.16c, which is 93.48f, following adminisration of 8l saline. patient was breifly in a bair hugger in icu but her temperature quickly normalized and remained so for the rest of her hospital stay. her tsh and morning cortisol were within normal limits. . #. hypotension: resolved by arrival in the icu, unlikely sepsis. likely secondary to medication interactions (i.e. benadryl, klonipin, mexilitine) and/or side effect. no evidence of pna or uti. troponin negative. hypotension, as well as cardiogenic shock, are listed as adverse reactions to mexilitine overdose. she may have ingested other medications that we are unaware of. the acuity of onset of her symptoms would suggest ingestion and not sepsis. could be addisonian crisis given slightly elevated eos, hyperkalemia and mild hyponatremia, already received 10mg dexamethasone. the patient's blood pressure responded well to the dexamethasone. random cortisol was within normal limits, however. . #bradycardia: baseline is in the 50s. given degree of bradycardia at time of ed presentation, could consider nodal [**doctor last name 360**] ingestion but could also have been vagal episode if post-ictal. patient resolved back to baseline by morning after admission. baseline bradycardia precludes use of betablocker in her, despite history of cad. . #altered mental status: likely secondary to high clonazepam dosing in light of liver failure, exacerbated by hypotension and drug side effect of mexilitine. appears to have happened repeatedly before around time of her dosing and also given her extremely large doses of clonazepam (9mg per day). the patient was alert upon admission to icu, so she was not given flumazenil. her confusion cleared in icu and remained clear throughout therefter. [**hospital **] medical regimen was adjusted, and patient was instructed not to drive or operate heavy machinery. she was instructed not to take ambien, benadryl, tizanidine, thorazine, or prednisone until she had spoken with her pcp. . # utox (+) amphetamine: can be a false positive due to klonipin, or other unreported otc medication. patient did not endorse amphetamine use. has no history of drug use. reports taking only that prescribed. . #. hyperkalemia, along with mild hyponatremia. possible hypoadrenalism considered in icu, but random cotrisol level within normal limits, and no other probable association. this resolved. . #. transaminitis: the patient had transaminitis upon icu admission, likely secondary to mexilitine as this has been described. possibly made worse by hypotension. acetaminophen level negative. no evidence of acute liver failure as inr and bilirubin normal. trnasaminases improved, but will need to be followed as outpatient. her medications were adjusted given degree of elevated liver enzymes. mexilitine was discontinued, especially as she was taking this for chronic pain, not antiarrhythmic. she agreed to get repeat lfts done in 48 hrs with her pcp [**name initial (pre) **]/or neurologist. she was instructed to stop zocor completely. . #. depression. patient does have recent stressor of son's death. the patient had a 1:1 sitter during her icu stay, though at no time reported intent to harm self or suicidal ideation. when i met her on the medical floor, the patient similarly denied si, and has no known history of this. has very supportive husband, and friend [**name (ni) **], and supportive relationship with her daughter. i discontinued 1:1. she agree to meet with psychiatry consult who agreed with non suicidal status. i made recommendations to adjust her antidepressant regimen (which was higher than maximum recommended dose to begin with) in light of her lft abnormalities. patient has a grief counselor and [**name (ni) 2447**]. she was instructed to follow up with the latter this week (and indicated that she had an appointment the day after admission, back in [**state 760**], where she lives). celexa was moved from 40mg [**hospital1 **] to 20mg [**hospital1 **] given her hepatotoxicity. wellbutrin was moved from 300mg daily to 150mg daily. . #. normocytic anemia: normal iron studies, b12, and folate. consider colonoscopy as outpatient procedure. . # chronic pain: is on incredibly high doses of gabapentin (1600mg tid) chronically, which supersedes the maximal recommended dose (even for short term dosing). this was moved to 800mg tid. she was also on an off-label use of mexilitine. mexilitine is likely cuplprit for hepatotoxicity, so this was discontinued. she described takin intermittent tizanidine until about 1 week ago, as well as intermittent periodic prednisone tapers (over 2 weeks) and thorazine regimens (for 5 days) for her pain esacerbations. she was instructed to not take mexilitine, prednisone, tizanidine at all, to follow up with her pcp, [**name10 (nameis) 2447**] and neurologist to make sure that all were speaking with each other about dose of medications being taken. polypharmacy is causing dangerous side effects. . # insomnia: chronic. takes beandryl and ambien at night. she was instructed to stop these medications completely until further instruction by her pcp or [**name10 (nameis) 2447**]. they have high risk of side effects. medications on admission: -levoxyl 50 mcg tab oral 1 tablet(s) once daily -gabapentin 1600mg tid -etodolac 300 mg cap oral 1 capsule(s) three times daily -mexiletine 250 mg qam, 250mg qnoon and 250mg qpm -bupropion hcl xl 300 mg 24 hr tab oral 1 tablet extended release 24 hr(s) once daily -naproxen 250 mg tab oral unknown # of dose(s) 550 mg tablet 3 times a day as needed for headache -chlorpromazine 25 mg tab oral 1 tablet(s) every hr as needed for severe ha max 5 tablets a day -benadryl prn insomnia -zocor 40mg q24 -asa 81mg daily - clonazepam 2mg qam, 3mg qnoon, 2.5mg q1600, 2mg q2100 - benefiber - celexa 40mg [**hospital1 **] discharge medications: 1. clonazepam 1 mg tablet sig: one (1) tablet po every six (6) hours: you may take maximum of 2mg per dose only if needed, but start with 1mg dose. 2. bupropion hcl 150 mg tablet extended release sig: one (1) tablet extended release po once a day. 3. citalopram 20 mg tablet sig: two (2) tablet po bid (2 times a day). 4. levothyroxine 50 mcg tablet sig: one (1) tablet po once a day. 5. neurontin 800 mg tablet sig: one (1) tablet po three times a day: do not exceed this dose, call your neurologist [**2104-3-4**]. 6. aspirin, buffered 500 mg tablet sig: one (1) tablet po once a day. discharge disposition: home discharge diagnosis: toxic encephalopathy -- most likely medication induced hepatotoxicity hypotension - resolved chronic depression and anxiety chronic pain syndrome discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted with change in mental status which we feel is due to side effects of your medications. you denied intent to hurt yourself, or taking non-prescribed meds, or additional doses of prescribed medications. you were seen by myself and a [**month/day/year 2447**] and understand the concerns i have regarding polypharmacy around your psychiatric and pain regimen. you understand that you have liver toxicity very likely related to you medications and low blood pressure component on hospital arrival (also medication induced), and that this requires cessation of particular meds, adjustment of dosage of other meds, and that blood work needs to be followed up this week by your physicians. please take meds as prescribed in the discharge list only. you have agreed to call your [**month/day/year 2447**] today or tomorrow to be seen in the next 1-2 days. if you cannot get in with your [**month/day/year 2447**] or pcp or neurologist, please let them know you need to have repeat liver function tests performed with advice on how to adjust your medications. i have recommended that you stop mixelitine (which you are taking for an off-label reason) and stop zocor completely. other adjustments to your medications have been made, please make a note of this. also, please do not take ambien, benadryl, tizanidine, thorazine, or prednisone until you have spoken with your pcp. do not drive or operate heavy machinery until approved to do so by your psychiatristm, neurologist, and/or pcp. you should tell your physicians your liver function tests were as follows: alt ast ld(ldh) ck(cpk) alkphos totbili dirbili [**2104-3-3**] 05:00 371* 253* 66 0.3 [**2104-3-2**] 23:47 492* 427* 400* 60 75 0.2 [**2104-3-2**] 10:30 143* 118* 347* 39 0.2 followup instructions: call your pscyhiatrist no later than tomorrow morning. call your neurologist and pcp [**name initial (pre) **]. make sure all your physicians are aware of your hospitalization and the medication changes i have recommended. you need repeat blood work in 48 hours (liver function tests).",1
94,"admission date: [**2106-3-10**] discharge date: [**2106-3-18**] date of birth: [**2027-2-16**] sex: m service: cardiothoracic allergies: procardia / isosorbide attending:[**first name3 (lf) 1267**] chief complaint: dyspnea major surgical or invasive procedure: [**2106-3-10**] three vessel coronary artery bypass grafting utilizing left internal mammary to left anterior descending, and vein grafts to ramus intermedius and posterior descending artery history of present illness: this 79 year old man has a history of emphysema and an imi in [**2085**]. he has never undergone cardiac catheterization and through the years has been managed on medication only without any symptoms. he denies any recent chest pain or change in activity tolerance but does note stable shortness of breath with moderate exertion which he attributes to his pulmonary disease. this can occur with climbing two to three flights of stairs, bending down to pick something up or walking up an incline. the patient is very hard of hearing and was recently scheduled to have a right cochlear implant at the [**location (un) 10866**]. in preparation for surgery, he was referred for cardiovascular preoperative testing as noted below. because of the results of his testing, his surgery has been cancelled and the patient has elected to come back to [**location (un) 86**] for further cardiology care. patient denies pnd, orthopnea, edema. he does note some bilateral calf discomfort with walking approximately five minutes at a fast pace. the left leg is worse than the right. cardiac catheterization on [**2106-3-5**] revealed severe three vessel disease. left ventriculography showed a depressed ejection fraction(46%) with posterobasal akinesis. coronary angiography was notable for a right dominant system; the lad had an 80% ostial lesion; the ramus had an 80% stenosis; while the circumflex and right coronary arteries were totally occluded. based on the above results, he was referred for cardiac surgical intervention. past medical history: coronary artery disease, prior imi, congestive heart failure, mild to moderate aortic insufficiency, mild mitral regurgitation, emphysema, hypertension, hyperlipidemia, peripheral vascular disease with claudication, vertigo, gout, gerd, deafness - s/p cochlear implant, s/p labyrinthectomy, s/p discectomy, varicocele, s/p shoulder surgery social history: patient is married with six children. he lives half of the year in [**state 108**] and half the year in [**hospital1 392**]. he previously worked as an elevator mechanic. patient's hearing is extremely poor and he is quite dependent on his wife for communication. he requires that you speak in a very loud, slow voice as words sound garbled to him. he does rely on lip [**location (un) 1131**] to assist in his communication. family history: uncle with angina his 60's. physical exam: vitals: bp 165/76, hr 64, rr 16, sat 98% on room air general: pleasant, well developed male in no acute distress heent: oropharynx benign, upper dentures neck: supple, no jvd, heart: regular rate, normal s1s2, no murmur or rub lungs: clear bilaterally abdomen: soft, nontender, normoactive bowel sounds ext: warm, no edema, no varicosities pulses: 2+ distally neuro: nonfocal, hard of hearing pertinent results: [**2106-2-2**] ett: 4 minutes 27 seconds [**doctor first name **] protocol, 85% max phr, stopping due to shortness of breath and fatigue. immediately post exercise the patient was noted to have diffuse pulmonary wheezing. ekg did not reveal evidence of ischemia with stress. imaging was notable for an inferior lateral perfusion defect that was moderately reversible. ef noted at 55%. [**2106-2-2**] echo: mild concentric lvh with an lvef of 50-55%. moderate mr, moderate ai, mild tr, mild pulmonary hypertension. [**2106-2-8**] carotid u/s: no significant disease noted. [**2106-2-8**] abi's: moderate to severe stenosis of the superficial femoral and popliteal arteries bilaterally. abi's 1.0. echo [**2106-3-10**]:pre-cpb: there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild global left ventricular hypokinesis. overall left ventricular systolic function is low normal (lvef 50-55%). the ascending aorta is mildly dilated. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets are mildly thickened. there is no aortic valve stenosis. mild to moderate ([**1-18**]+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is slight retraction of both mitral valve leaflets. moderate (2+) central mitral regurgitation is seen with systolic blood pressures of around 150 mmhg. at lower sbp (around 110) the mr is mild to moderate. post-cpb normal biventricular systolic function. valvular abnormalities noted in pre-cpb study remain. cxr [**3-17**]: no chf with stable left pleural effusion. sternal wires in unchanged position. [**2106-3-10**] 01:13pm blood wbc-11.0# rbc-2.57*# hgb-8.4*# hct-23.1*# mcv-90 mch-32.9* mchc-36.5* rdw-13.3 plt ct-106*# [**2106-3-12**] 02:14am blood wbc-11.5* rbc-3.42* hgb-10.8* hct-31.2* mcv-91 mch-31.6 mchc-34.6 rdw-13.5 plt ct-148* [**2106-3-18**] 06:25am blood wbc-9.8 rbc-3.70* hgb-11.9* hct-34.5* mcv-93 mch-32.1* mchc-34.5 rdw-13.7 plt ct-450* [**2106-3-10**] 01:13pm blood pt-16.7* ptt-36.8* inr(pt)-1.5* [**2106-3-12**] 08:30pm blood pt-13.4* ptt-27.9 inr(pt)-1.2* [**2106-3-10**] 02:40pm blood urean-17 creat-1.0 cl-112* hco3-22 [**2106-3-12**] 08:30pm blood glucose-128* urean-22* creat-1.3* na-137 k-4.4 cl-101 hco3-27 angap-13 [**2106-3-18**] 06:25am blood urean-22* creat-1.5* k-3.6 [**2106-3-12**] 02:14am blood calcium-8.4 phos-4.6*# mg-2.0 [**2106-3-11**] 04:03am blood freeca-1.29 brief hospital course: on the day of admission, mr. [**known lastname 32793**] [**last name (titles) 1834**] three vessel coronary artery bypass grafting by dr. [**last name (stitle) **]. the operation was uneventful - see operative note for further details. following the operation, he was brought to the csru. within 24 hours, he awoke neurologically intact and was extubated. he maintained stable hemodynamics and transferred to the sdu on postoperative day two. he experienced bouts of paroxysmal atrial fibrillation which was treated with amiodarone. he remained mostly in a normal sinus rhythm and did not require warfarin anticoagulation. on postoperative day five, he displayed new onset paranoia with visual hallucinations. the timing of his symptoms did raise the possibility of adverse reaction to percocet. he intermittently required haldol and was assigned to a one on one sitter for safety. the psych service was consulted and felt this event was related to narcotic analgesia. opiates, benzos and anticholinergics were avoided. over the next 24 hours, his mental status improved and by discharge, returned to baseline. over several days, he continued to make clinical improvements. because of some mild sternal drainage, he was empirically placed on antibiotics. he was eventually cleared for discharge to home with vna services on postoperative day 8. at discharge, his bp was 132/65 with a hr of 88. he will follow-up with dr. [**last name (stitle) **] and his cardiologist and pcp. medications on admission: lopressor 50 [**hospital1 **], zocor 40 qd, aspirin 325 qd, albuterol mdi, glucosamine, zantac, mvi, coenzyme q10 discharge disposition: home with service facility: [**location (un) 86**] vna discharge diagnosis: coronary artery disease s/p coronary artery bypass graft x 3 postoperative narcotic induced delirium sternal drainage prior imi congestive heart failure mild to moderate aortic insufficiency mild mitral regurgitation emphysema hypertension hyperlipidemia peripheral vascular disease vertigo gout gerd deafness - s/p cochlear implant s/p labyrinthectomy, s/p discectomy, varicocele, s/p shoulder surgery discharge condition: good discharge instructions: patient may shower, no baths. no creams, lotions or ointments to incisions. no driving for at least one month. no lifting more than 10 lbs for at least 10 weeks from the date of surgery. monitor wounds for signs of infection. please call with any concerns or questions. followup instructions: cardiac surgeon, dr. [**last name (stitle) **] in [**4-21**] weeks. local pcp, [**last name (namepattern4) **]. [**last name (stitle) **] in [**2-19**] weeks. local cardiologist, dr. [**last name (stitle) **] in [**2-19**] weeks. completed by:[**2106-4-16**]",1
95,"admission date: [**2170-10-17**] discharge date: [**2170-10-19**] date of birth: [**2126-8-23**] sex: m service: medicine allergies: erythromycin base / doxycycline / betadine / iodine attending:[**doctor first name 1402**] chief complaint: chest pain major surgical or invasive procedure: cardiac catheterization with rca stent placement history of present illness: pt is a 44 with dm, hyperchol, + smoking history who presents iwth 3 days of cp, arm pain and back pain. + sob, no n/v/d. states tonight had severe pain in chest associated with diaphoresis, sob which was also associated with pain in arms bilaterally. . of note pt started on lipitofr 5 days ago and stopped 2 days ago secondary to muscle aches and dark urine. . on ros denies doe, pnd orthopnea. past medical history: diabetes type ii hypertension social history: tobacco 25 pack year history currently smokes, +coccaine in past last use in the 80s. +social etoh. family history: grandfather with mi at 42, mother with cva at 68, a. fib. physical exam: afeb, hr 72 bp 140/77 bilaterally, rr 16 o2 96% . gen: middle aged male in nad lying in bed heent: no jvp elevation, perrl, mmm chest: ctab, no crackles cvr: rrr, nl s1, s2, no r/m/g abdomen: soft, obese, nt ext: groin site without hematoma, 2+ distal pulses bilaterally neuro: grossly intact. pertinent results: ecg nsr 2-3mm st elevation iii, f 2mm st elevation v3, v4, rightsided leads: 1mm ste v4r . cath: lmca 70%, lad 70% at origin of d1, lcx small, rca 100% prox occlusion with l to r collaterals. 2 [**name prefix (prefixes) **] [**last name (prefixes) 10157**] to rca. pcw 19, pa 39/17 rv 34/5 co 4.12, ci 2.06 . labs: ck 255, mb 11, mbi 4.3 trop 0.07 . echo [**2170-10-18**] conclusions: 1. left ventricular wall thickness, cavity size, and systolic function are normal. probably inferior hypokinesis is present; the inferior wall is not well seen. 2. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. brief hospital course: 44 yom with dm, htn, +tobb +hx of coccaine admitted with acute imi now s/p rca intervention. . # cad - initial ecg with inferior and anterior changes pt was taken to cath lab with pci to rca, also has lmca and lad disease. on hemodynamics right sided pressures ok. pt was continued on asa/plavix/bb. statin was held since recent adverse reaction. he also received integrillin x 18 hours. initially required nitro for ~2 hours post cath for bp mgmt. pt with no further complaints of pain. he may need cabg in the future for lmca, lad disease, and pt will follow up for this after discharge. # pump - euvolemic on exam, monitored for hypovlemia given imi, however there were no problems. echo performed the following day, results above. # rhythm - nsr . ## dm - ?outpt dose, riss inhouse and pt to restart home dose of meds after discharge. ## hypothyroid - continue outpt dose of synthroid. - will need repeat lfts at follow-up cardiology appointment to see if statin able to be rechallenged. patient arranged for sleep study on [**10-23**] to evaluate for osa, c-pap. also scheduled for f/u with ct [**doctor first name **] on [**11-20**] for evaluation for cabg. will see dr. [**last name (stitle) **]/dr. [**last name (stitle) 96833**] in cardiology on [**10-30**]. patient restarted on low dose [**last name (un) **], plavix, aspirin, and atenolol. recommended patient arrange follow-up at the [**hospital **] clinic for diabetes and thyroid care. medications on admission: all: betadiene, erythromycin current medications glipizide , synthroid 250, diovan 10 mg discharge medications: 1. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 2. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*1* 3. levothyroxine sodium 125 mcg tablet sig: two (2) tablet po daily (daily). 4. valsartan 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 5. atenolol 25 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*1* 6. plavix 75 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: coronary artery disease, stemi, s/p 2 stents placed in rca diabetes hypercholesterolemia tobacco abuse discharge condition: good- patient ambulating, has been evaluated by pt. hemodynamically stable on blood pressure medications. discharge instructions: you have been started on a number of new medications for your heart. please take these medications every day as instructed. please return to the hospital or call your doctor if you experience chest pain, shortness of breath, fevers, chills. please follow-up with your pcp within the next two weeks. please follow-up with cardiology at the appointment time listed below. we recommend following up at the [**hospital **] clinic for care of your diabetes and thyroid disease. in addition, you have an appointment with cardiothoracic surgery at the time listed below. please avoid work for the next week, and avoid heavy lifting or strenuous activity for the next two weeks. please avoid work for the next week, and heavy lifting or strenuous activity for the next 2 weeks. followup instructions: please schedule an appointment with your pcp within the next 2 weeks. please call the [**hospital **] clinic at [**telephone/fax (1) 27738**] to make an appointment for follow-up care of your diabetes and thyroid disease. you have an appointment with dr [**last name (stitle) **] in cardiothoracic surgery on [**11-20**] at 1:00pm at [**hospital unit name 96834**]. [**telephone/fax (1) 170**] you have an appointment scheduled with dr. [**last name (stitle) **] in cardiology on [**10-30**], his office will be contacting you with a confirmed time. please call [**telephone/fax (1) 5003**] with questions. completed by:[**2170-11-4**]",1
96,"admission date: [**2118-4-3**] discharge date: [**2118-4-25**] date of birth: [**2062-1-20**] sex: f service: [**hospital1 **]/medicine primary care physician: [**name10 (nameis) 39752**] [**name7 (md) 99173**], m.d. chief complaint: lower gastrointestinal bleed. history of present illness: this is a 56 year old greek female with a history of recurrent gastrointestinal bleeding, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease and other comorbidities, who presents from her nursing home with maroon stools times ten to fourteen days and bright red blood per rectum for the past two days. for the past ten to fourteen days, she has also had crampy intermittent lower left quadrant pain, nonexertional shortness of breath and moderate fatigue. falling hematocrit necessitated transfusion of two units of packed red blood cells at [**hospital6 13846**] center where she has been living for four months. she denies the following: chest pain, syncope, nausea, vomiting, dysphagia, dysuria or hematuria. she also denies a history of peptic ulcer disease or gastroesophageal reflux disease. she does report swelling and erythema of her legs which has been unchanged for the past six months. gastrointestinal bleeding history: 1. [**month (only) 404**] to [**2117-6-9**], recurrent gastrointestinal bleeds over these months requiring eighteen transfusions at various hospitals. 2. [**2117-6-9**], [**hospital3 **] hospital. video endoscopy did not reveal bleeding, upper endoscopy showed papular gastropathy but no source of chronic bleeding. 3. [**2117-7-10**], [**hospital3 **] hospital. colonoscopy revealed a single nonbleeding angiectasia in the transverse colon which was treated with electrocautery. 4. [**2117-8-9**], [**hospital3 **] and then transferred to [**hospital1 1444**] medical intensive care unit - presented at [**hospital3 **] with bright red blood per rectum, hematocrit fell from 28.0 to 12.0 and was transferred four units; transferred to [**hospital1 188**]. coumadin and heparin were held. there was a bleeding scan positive for bleeding from angiodysplasia of the cecum or ascending colon past the distal ileocolic artery. she received interventional radiology embolization of the right colon. coumadin and heparin were restarted after embolization. in addition, the patient was hypotensive throughout the admission with blood pressure nadiring at 82/30; her hematocrit on that admission 24.0, inr 2.6; and in this setting, she had a myocardial infarction with peak ck of 300 and troponin of 34. an echocardiogram showed an ejection fraction of 40%. in addition, the patient had a catheterization that showed one vessel disease which seemed chronic. she was transfused four units at [**hospital1 346**] for a total of eight. her hematocrit stabilized and bleeding was mostly resolved. 5. [**2117-9-9**], [**hospital1 69**] medical intensive care unit. the patient presented with bright red blood per rectum initially progressing to maroon colored stools plus intermittent substernal chest pain relieved with sublingual nitroglycerin. she was hypotensive to 99/56. her electrocardiogram showed 0.[**street address(2) 11725**] depressions in leads ii and iii. she ruled out for myocardial infarction and was transfused five units total. interventional radiology elected not to embolize due to the risk of mesenteric ischemia. coumadin and heparin were held. bleeding resolved. 6. [**2118-2-9**] - the patient presented to [**hospital6 14430**] with hypotension and malaise. colonoscopy showed a continuous area of nonbleeding shallow ulcer of the mucosa with no stigmata of recent bleeding present in the ascending colon distal to the cecum, three ulcers next to each other, largest 1.0 centimeter, nonbleeding internal hemorrhoids as well. past medical history: 1. gastrointestinal bleeds as above. 2. status post aortic valve replacement with a st. jude valve in [**2113**]. 3. congestive heart failure with transthoracic echocardiogram on [**2118-3-4**], showing normal left ventricular systolic function, inability to assess the ejection fraction due to irregular rhythm although an ejection fraction of 40% was shown on [**2117-8-25**]. right ventricle was dilated with moderately reduced systolic function. aortic valve prosthesis was well seated, no aortic insufficiency, 2+ mitral regurgitation, 3+ tricuspid regurgitation, pulmonary artery pressure 70 mmhg, mitral valve calcified at the commissures but mobile without stenosis, dilated inferior vena cava suggestive of elevated right heart diastolic pressures. 4. coronary artery disease. the patient is status post percutaneous transluminal coronary angioplasty in [**2100**]. she is status post multiple myocardial infarctions. cardiac catheterization on [**2117-8-25**], demonstrated 100% proximal right coronary artery stenosis with diffuse right coronary artery disease, not felt to repairable by angioplasty or bypass. septal inferior artery with 60% occluded, obtuse marginal 60% occluded and the first diagonal 20% occluded. 5. hypercholesterolemia. 6. atrial fibrillation, status post pacemaker placement. 7. history of rheumatic fever. 8. diabetes mellitus type 2. the patient is now requiring insulin. history of neuropathy and mild nephropathy. 9. chronic obstructive pulmonary disease. she requires home oxygen at three liters since [**2112**]. 10. klebsiella urinary tract infection in [**9-10**]. 11. depression. past surgical history: as above. 1. left atrial mass resection [**2113**], nonneoplastic infected atrial myxoma. 2. ovarian cyst removal. 3. cholecystectomy. allergies: no adverse reactions, no known drug allergies. medications on admission: 1. albuterol, ipratropium nebulizers four times a day. 2. aspirin 81 mg p.o. once daily. 3. captopril 6.25 mg p.o. three times a day. 4. digoxin 0.125 mg p.o. once daily. 5. docusate 100 mg p.o. twice a day. 6. furosemide 160 mg p.o. twice a day. 7. gabapentin 100 mg p.o. q.h.s. 8. metolazone 5 mg p.o. twice a day. 9. metoprolol 12.5 mg p.o. twice a day. 10. ocean spray nasal spray two puffs each naris three times a day. 11. nph insulin 26 units subcutaneous q.a.m., 6 units subcutaneous q.p.m. 12. protonix 40 mg p.o. once daily. 13. simvastatin 10 mg p.o. once daily. 14. spironolactone 25 mg p.o. once daily. 15. vitamin c 500 mg p.o. twice a day. 16. warfarin 5 mg p.o. q.h.s. 17. zinc sulfate 220 mg p.o. twice a day. social history: two to three pack per day smoker since the age of 14, 70 to 100 pack years total. quit six years ago. no alcohol use. had lived at home with husband until four months ago when she moved to [**hospital6 13846**] center. family history: mother with type 2 diabetes mellitus. physical examination: vital signs revealed a temperature 97.6, pulse 89, respiratory rate 20, blood pressure 105/60. oxygen saturation 100% on three liters. in general, this is an elderly female with mild respiratory distress, alert, cooperative and oriented times three. cranium was normocephalic and atraumatic. the pupils are equal, round, and reactive to light and accommodation. extraocular movements are intact. sclera anicteric. mucous membranes are slightly dry, no lymphadenopathy. difficult to assess jugular venous distention. bilateral bibasilar crackles on auscultation. irregularly irregular rhythm, s1, mechanical s2, grade iii/vi holosystolic ejection murmur radiating to the axilla. large pannus, normoactive bowel sounds, soft, nontender, nondistended. stools guaiac positive. no costovertebral angle tenderness. extremities - 2+ edema in the lower extremities bilaterally. kyphoscoliotic changes. cranial nerves ii through xii are intact. strength and sensation are intact. no rashes. laboratory data: on admission, sodium 137, potassium 3.6, chloride 94, bicarbonate 32, blood urea nitrogen 26, creatinine 0.7, glucose 107. calcium 8.1, magnesium 1.4, albumin 2.8. inr 1.9. hematocrit 27.6, white blood cell count 7.6, platelet count 320,000. electrocardiogram on admission showed no significant change since electrocardiogram on [**2117-10-5**], atrial fibrillation, premature ventricular contractions or aberrant ventricular conduction, incomplete right bundle branch block, extensive but nonspecific st-t wave changes. chest x-ray was consistent with congestive heart failure. the heart is enlarged. cardiac pacer device is seen and sternal clips consistent with prior coronary artery bypass graft. hospital course: in the emergency department, the laboratories and studies reported above were obtained. her systolic blood pressure dropped to the 80s and she received intravenous fluids 500cc bolus normal saline and then 100cc and made 900cc of urine in three hours. she received two units of packed red blood cells because of her hematocrit. she also received levofloxacin and metronidazole intravenously for empiric coverage of gastrointestinal infection. she was admitted to the medical intensive care unit. her anticoagulants were held and her gastrointestinal bleeding gradually decreased. the colonoscopy was obtained on [**2118-4-6**], which was normal to the cecum and terminal ileum. however, ulcers in the hepatic flexure possibly from ischemia were noted. bicap cautery was applied to a small red spot that was considered stigmata of previous bleeding, no recurrent arteriovenous malformations were seen, however, prep was very poor. biopsies were not taken. dr. [**last name (stitle) **] of gastroenterology was involved in her care. also in the medical intensive care unit, cardiology evaluated the patient as moderate risks for perioperative and postoperative complications and made recommendations for intraoperative management if hemicolectomy was part of her potential management. the patient was started on heparin and transferred out of the medical intensive care unit. on the medical floor, the patient's heparin was titrated to achieve a goal partial thromboplastin time between 60 and 80. she did not experience any more gross blood per rectum. her stools with two exceptions were guaiac negative. her hematocrit stabilized around 30.0. during the rest of her stay, she experienced one episode of respiratory distress with a bump in her troponin level of 7.6 which was believed to be due to an acute exacerbation of her congestive heart failure. pulmonary evaluated the patient on [**2118-4-11**], and reported moderately severe obstructive airways disease likely due to emphysematous and moderately severe restrictive lung dysfunction, low tlc likely due to kyphosis, obesity and right effusion. her pulmonary function tests showed the tlc 53% of predictive, fev1 0.74 which was 34% of predicted, fvc 1.31, fev1/fvc ratio 74% of predicted. it is believed that there would be a significant risk of pulmonary problems. [**name (ni) 6**] echocardiogram was obtained on [**2118-4-15**]. the left atrium was moderately dilated, overall left ventricular systolic function was estimated near normal, left ventricular ejection fraction greater than 55%, right ventricular cavity was moderately dilated. it was believed the patient risk of having colectomy outweighed risk of leaving the patient with less anticoagulation given her poor cardiopulmonary status. it was believed that a repeat colonoscopy with biopsy with an excellent preparation would help us better assess the source of her bleeding and would aid in the nonoperative management of future gastrointestinal bleeds. the patient refused the procedure. the patient's clinical picture continued to improve with aggressive diuresis. she was transitioned from heparin to warfarin. condition on discharge: her condition on discharge was improved. discharge diagnoses: 1. gastrointestinal bleed. 2. congestive heart failure. 3. status post aortic valve replacement. 4. coronary artery disease. 5. chronic obstructive pulmonary disease. 6. atrial fibrillation. 7. diabetes mellitus type 2. 8. hypercholesterolemia. medications on discharge: 1. albuterol inhaler two puffs four times a day. 2. captopril 6.25 mg p.o. three times a day. 3. digoxin 0.125 mg p.o. once daily. 4. furosemide 120 mg p.o. three times a day. 5. gabapentin 100 mg p.o. q.h.s. 6. insulin. 7. ipratropium inhaler two puffs four times a day. 8. metolazone 5 mg p.o. twice a day. 9. metoprolol 12.5 mg p.o. twice a day. 10. pantoprazole 40 mg p.o. once daily. 11. simvastatin 10 mg p.o. once daily. 12. spironolactone 25 mg p.o. once daily. 13. warfarin 2.5 mg p.o. q.h.s. 14. sulfadem 5 mg p.o. q.h.s. p.r.n. discharge status: she will return to her rehabilitation facility. [**doctor first name 1730**] [**name8 (md) 29365**], m.d. [**md number(1) 29366**] dictated by:[**last name (namepattern1) 9128**] medquist36 d: [**2118-4-24**] 10:49 t: [**2118-4-24**] 12:22 job#: [**job number 99174**]",0
97,"admission date: [**2153-11-15**] discharge date: [**2153-12-13**] date of birth: [**2098-12-8**] sex: m note: this is a discharge summary addendum. it will cover the period of [**2153-12-9**] until [**2153-12-13**]. hospital course by issue/system: 1. cardiovascular system: the patient with endocarditis. he was started on vancomycin. once the sensitivities came back, he was switched to nafcillin and then nafcillin/oxacillin; for which it was believed he had an adverse reaction where his liver transaminases began to elevate. the decision was made to switch the patient to intravenous vancomycin, on which he will remain for six 2. infectious disease issues: the patient was followed by the infectious disease service who recommended that the patient remain on vancomycin until [**2153-12-30**]. this will complete a 6-week course from the patient's first set of negative cultures. of note, the patient's plasma creatinine should be checked on an every-other-day basis to adequately dose his vancomycin. if the patient's creatinine is greater than 1.3, his vancomycin dose should be every 18 hours. if his creatinine is 1.2 or less, then the patient's vancomycin dose should be given every 12 hours. the patient was scheduled for a followup with the infectious disease service on [**12-21**] on the sixth floor of the [**doctor last name 780**] building at 9 a.m. 3. gastrointestinal system: the patient with a history of hepatitis c with cirrhosis. during this admission, his alt and ast started to become elevated. he was switched from oxacillin/nafcillin to vancomycin. the hepatology service followed the patient and initially wanted a liver biopsy to further evaluate the cause of the elevated transaminases. a computed tomography scan was performed which showed a stable appearance of multiple wedge-shaped infarcts involving the right kidney and spleen along with a cirrhotic liver. on the day the patient was scheduled to have his biopsy, his transaminases improved, and the decision was made to postpone a liver biopsy at that time. discharge disposition: he was discharged to a rehabilitation home for intravenous antibiotic treatment. discharge instructions/followup: (his discharge instructions were) 1. the patient was to follow up with the infectious disease service on [**2153-12-21**] at 9 o'clock. 2. the patient was also to follow up with cardiothoracic surgery following completion of his intravenous antibiotics for evaluation of valve replacement. medications on discharge: (discharge medications were as follows) 1. vancomycin 1000 mg intravenously q.12h.; note, the patient should have his plasma creatinine checked every other day, and his vancomycin dose should be adjusted accordingly. if his plasma creatinine is less than 1.3, the patient should have 1000 mg intravenously every 12 hours. however, if his creatinine is 1.3 or greater, then his vancomycin should be dosed every 18 hours. 2. ambien 5 mg to 10 mg p.o. q.h.s. as needed. 3. lactulose 30 ml p.o. q.8h. p.r.n. (titrate to two bowel movements per day). 4. spironolactone 25 mg p.o. q.d. (hold for a systolic blood pressure of less than 100). 5. oxycodone sustained release 10 mg p.o. every 12 hours. 6. metoprolol 12.5 mg p.o. b.i.d. 7. colace 100 mg p.o. b.i.d. 8. lisinopril 5 mg p.o. q.h.s. 9. tramadol 100 mg p.o. q.4-6h. as needed 10. sodium chloride nasal spray 1 to 2 sprays per nostril q.i.d. as needed. 11. bacitracin ointment applied to the lesions on the right knee and left buttocks biopsy sites every day. 12. gabapentin 300 mg p.o. q.d. 13. pantoprazole 40 mg p.o. q.d. discharge diagnoses: (discharge diagnoses included) 1. endocarditis; staphylococcus aureus. 2. malnutrition 3. former history of alcohol and intravenous drug use -- in remission. 4. hepatitis c with cirrhosis. 5. hypertension. 6. bilateral lower extremity edema vasculitis. 7. acute renal failure. [**name6 (md) 7853**] [**last name (namepattern4) 7854**], m.d. [**md number(1) 7855**] dictated by:[**name8 (md) 6284**] medquist36 d: [**2153-12-13**] 08:16 t: [**2153-12-13**] 08:34 job#: [**job number 31813**]",1
98,"admission date: [**2124-11-4**] discharge date: [**2124-11-23**] service: surgery allergies: penicillins / erythromycin base / iodine; iodine containing / demerol / codeine / lopressor / morphine attending:[**first name3 (lf) 974**] chief complaint: 1. melena 2. lightheadiness 3. abdominal pain major surgical or invasive procedure: [**11-7**]:egd and colonoscopy [**11-14**]:left colectomy and splenectomy [**11-19**]:picc line placement blood transfusion x 2 ([**11-4**], [**11-15**]) history of present illness: this is a [**age over 90 **] year-old female w/ h/o dm2, htn, cad, duodenitis, arthritis, s/p recent admission for bronchitis who presents from rehab c/o 4-day h/o melena, lightheadiness, and abdominal pain. the patient reports that 4 days pta she suddenly developed diarrhea with production of black stool. she had six episodes of large black stool 4 days pta, five episodes 3 days pta, three episodes 1 day pta and last bm was yesterday evening in the ed. she states that the volume is usually large. she denies any pain with defecation and has not noticed any bright red blood in her stool. she denies any h/o melena or bright red blood in her stool. she usually has 1 bm per day or every other day. she denies epistaxis, bleeding gums, or easily bruising. in addition, she also reports weakness and mild lightheadedness with ambulation starting 4 days pta. she had difficulties walking. she usually is active and walks a lot with her cane. she denies any headaches, fall or loc. she has been taken her insulin and diabetic mediation as directed and denies any change in her diabetic diet recently. she also c/o abdominal ""ache"" located in her upper right and left abdominal quadrants, which is not affected by po intake. she denies any n, v and reports that her appetite is fair but she has been able to tolerate po intake without problems. she states that she has had chronic abdominal pain in that location and is not sure if this abdominal pain has changed from before and if it is acute. she had a voluntary weight loss of 40lbs over the last several months. she has not taken any weight loss supplements. she changed her diet and walked a lot. she eats usually fish and chicken, with vegetables, and occasionally fruits. she denies any recent antibiotic, steroid or nsaid intake. the patient also reports an episode of cp - a ""twinge"" yesterday morning. she states that she has had this type of cp for years and it is unchanged from prior. at home she takes slng for it. it is not related to exercise and comes on rarely. she has occasional pnd and uses two pillows to sleep. she denies any dyspnea and is able to walk several flights of stairs without dyspnea. she denies diaphoresis. in the ed: vs 96.8, 76, 155/63 the patient was guaiac pos without gross blood. a ng lavage was negative. wbc 11.2 with left shift, hct 31.1, cr 1.5, lactate 2.9, lipase and amylase slighly elevated. cardiac enzyme x 1 negative. she was given 1l of ns and 1l of d5w w/ nahco3 for cin prevention. ct abd was unremarkable except for an assymetric focus of wall thickening in descending colon. the patient was admitted to the medicine service for further work-up and management. past medical history: 1. hypertension 2. type ii diabetes with retinopathy and renal dysfunction 3. coronary artery disease with a catherization in [**2116**] that showed 40% distal rca and diffuse om1 disease. she had a normal p-mibi in [**2121-1-26**]. 4. legally blind secondary to diabetic retinopathy & anterior ischemic optic neuropathy. 5. arthritis, dupuytren's 6. status post excision of bladder tumor [**2120-2-19**] 7. status post left tka 8. status post cholecystectomy 9. status post bilateral cataract extractions 10. status post herniorrhaphy x 3 11. status post hysterectomy age 30 social history: tobacco: h/o 3 cig/day x 1 year, quit 50 years ago etoh: denies, no h/o alcoholism illicit drugs: denies, no ivdu she lives alone at mission [**doctor last name **] and is independent. she is widowed, legally blind. she is a retired nursing assistant who worked at nebh for 20 yrs. she has 2 sons in the [**name (ni) 86**] area and 1 son in [**name (ni) 4565**]. she has 8 grandchildren and 5 great-grandchildren. she is currently at [**hospital3 **] ([**telephone/fax (1) 7233**]). family history: mother died at age 53 of nephritis and father did at age [**age over 90 **]. no h/o gi bleed, colon cancer, dm, asthma, heart disease physical exam: vs: t:97.0f hr:72 regular bp:132/70 rr:18 o2sat:97%ra general:appears younger than stated age, nad, resting comfortably in bed skin: no scalp, face, or neck lesions/abrasions/lacerations heent: nt/ac. perrla, eomi. petechiae on lateral sides of tongue? oropharynx clear. no tonsillar enlargement. tongue moves to left and right. neck: no lymphadenopathy. supple, non-tender, no jvd or carotid bruises appreciated. trachea midline. thyroid gland with no masses pulm: normal excursion. cta bilaterally. no crackles or wheezes. cv: rrr, normal s1, s2, no s3 or s4. ii/vi holosystolic ejection murmur. abd: soft, tender to palpation in right and left upper quadrants, non-distended, +bowel sounds. no hepatomegaly, no spleenomegaly. no cva tenderness. ext: +1 pitting edema in le bilaterally. no clubbing, jaundice or erythema. numbness in both feet. no dp or pt pulses appreciated. neuro: a/ox3. no abnormal findings. pertinent results: radiology: ct abdomen ([**2124-11-4**]): impression: 1. colonic diverticulosis without acute diverticulitis. 2. focal wall thickening of descending colon of unclear etiology however correlation with colonoscopy is recommended as indicated to exclude a neoplastic process. 3. atherosclerotic changes of abdominal aorta and its branches with infrarenal ectasia without frank aneurysm. atrophic left kidney. 4. previously noted enhancing bladder mass not definitively identified today. bilat lower ext veins [**2124-11-8**] 3:37 pm impression: no deep vein thrombosis in the lower extremities. transthoracic echocardiogram, [**11-13**]: impression: normal biventricular cavity sizes with preserved global and regional biventricular systolic function. mild mitral regurgitation. compared with the prior study (images reviewed) of [**2124-8-4**], the findings are similar chest (portable ap) [**2124-11-16**] 11:29 pm impression: bilateral pleural effusions, with a question of a possible pulmonary infarct on the right ct chest w/o contrast [**2124-11-17**] 7:58 pm lateral right lower lung opacity reflects combination of layering effusion and multifocal right-sided pneumonia as described above. given patient's age, postoperative status and fairly dependent positioning, aspiration is favored. no wedge shaped opacities to suggest infarct. small-to-moderate bilateral simple pleural effusions with adjacent compressive atelectasis. marked narrowing of the bronchus intermedius likley related to focal bronchomalacia. dilated pulmonary artery. endoscopy: colonoscopy [**11-7**]: polyp in the transverse colon (biopsy),polyp in the descending colon (biopsy), mass in the 45cm (biopsy, injection), diverticulosis of the sigmoid colon and descending colon egd [**11-7**]: mild erythema in the antrum and stomach body compatible with mild gastritis, small hiatal hernia, submucosal venous structure in the mid-esophagus. pathology: colon bx from colonoscopy [**11-7**]: a) ascending colon polyp, biopsy: adenoma. b) transverse colon polyp, biopsy: adenoma. c) mass at 45 cm, biopsy:colonic mucosa with a single fragment of neoplastic epithelium. the neoplastic fragment is scant and is not associated with intact mucosa tissue; thus, further interpretation is not possible. it may represent adenoma, adenocarcinoma, or carry-over artifact. surgical pathology, 11/20 l colectomy: t3 lesion, n0 (0 of 13 nodes positive), clear margins [**2124-11-4**] 09:50am glucose-78 urea n-33* creat-1.4* sodium-145 potassium-4.1 chloride-108 total co2-26 anion gap-15 [**2124-11-4**] 09:50am ck(cpk)-42 amylase-112* [**2124-11-4**] 09:50am lipase-106* [**2124-11-4**] 09:50am ck-mb-notdone ctropnt-<0.01 [**2124-11-4**] 09:50am calcium-8.4 phosphate-2.9 magnesium-2.4 [**2124-11-4**] 09:50am wbc-10.6 rbc-3.00* hgb-8.6* hct-25.9* mcv-86 mch-28.8 mchc-33.4 rdw-15.3 [**2124-11-4**] 09:50am plt count-373 [**2124-11-3**] 09:52pm urine hours-random [**2124-11-3**] 09:52pm urine gr hold-hold [**2124-11-3**] 09:52pm urine color-straw appear-clear sp [**last name (un) 155**]-1.009 [**2124-11-3**] 09:52pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg [**2124-11-3**] 07:39pm k+-4.8 [**2124-11-3**] 06:52pm type-[**last name (un) **] comments-green top [**2124-11-3**] 06:52pm glucose-151* lactate-2.9* na+-141 k+-6.2* cl--106 [**2124-11-3**] 06:52pm hgb-10.1* calchct-30 [**2124-11-3**] 05:55pm glucose-160* urea n-43* creat-1.5* sodium-138 potassium-6.3* chloride-104 total co2-20* anion gap-20 [**2124-11-3**] 05:55pm estgfr-using this [**2124-11-3**] 05:55pm alt(sgpt)-13 ast(sgot)-34 alk phos-59 amylase-135* tot bili-0.3 [**2124-11-3**] 05:55pm lipase-102* [**2124-11-3**] 05:55pm albumin-4.0 calcium-8.8 phosphate-3.4 magnesium-2.6 [**2124-11-3**] 05:55pm wbc-11.2* rbc-3.49* hgb-10.1* hct-31.1* mcv-89 mch-28.9 mchc-32.5 rdw-15.1 [**2124-11-3**] 05:55pm neuts-86.9* bands-0 lymphs-10.3* monos-2.4 eos-0.2 basos-0.2 [**2124-11-3**] 05:55pm hypochrom-1+ anisocyt-normal poikilocy-occasional macrocyt-normal microcyt-normal polychrom-normal ovalocyt-occasional teardrop-occasional [**2124-11-3**] 05:55pm plt smr-high plt count-494*# [**2124-11-4**] 09:50am blood wbc-10.6 rbc-3.00* hgb-8.6* hct-25.9* mcv-86 mch-28.8 mchc-33.4 rdw-15.3 plt ct-373 [**2124-11-4**] 09:50am blood glucose-78 urean-33* creat-1.4* na-145 k-4.1 cl-108 hco3-26 angap-15 [**2124-11-4**] 09:50am blood ck(cpk)-42 amylase-112* [**2124-11-4**] 09:50am blood lipase-106* [**2124-11-4**] 09:50am blood calcium-8.4 phos-2.9 mg-2.4 brief hospital course: [**age over 90 **] year-old female w/ h/o dm2, htn, cad, recent diagnosis of duodenitis, arthritis, s/p recent admission for bronchitis who presented from rehab c/o 4-day h/o melena, lightheadedness, and abdominal pain. she underwent egd and colonoscopy on [**11-7**] (reports above) when a l colon mass was found and biopsies taken. surgical course: the general surgery team was consulted on [**11-8**] in regards to the mass found in the left colon on colonoscopy. it was determined that the patient would require surgical resection of the left colon and she was booked for surgery on [**2124-11-14**]. on the night prior to surgery she underwent a bowel prep. during the procedure the left colon was successfully resected in an open procedure. the mass was located in the splenic flexure. her tissue in this region was noted to be quite friable and there was injury to spleen during mibilization of the flexure. it was decided to perform a splenectomy to avoid possible bleeding complications. a central line and [**initials (namepattern4) **] [**last name (namepattern4) 3389**] local anesthesia pump were placed intraoperatively. post-operatively she was taken to the pacu and remained there overnight for increased monitoring giving the amount of intraoperative blood loss and her age/comorbidities. secondary to altered mental status (sedation and then agitation) as well as decreased respiratory drive and continued o2 requirement, she was transferred from the pacu to the trauma surgical icu. the patient experienced delerium on transfer to the icu which she gradually recovered from over the following days, returning to her baseline mental status. postoperative cxr's were suggestive of a r lung wedge infarct, which seemed unlikely. therefore a ct of the chest was performed to confirm this diagnosis(without contrast given reports of prior adverse reaction), which did not show any pulmonary infarct, but did show a rll pneumonia. zosyn was started empirically for nosocomial pneumonia. on [**11-16**] the patient was transferred to the surgical floor, however on [**11-18**] she went into rapid a-fib with some hemodynamic instability (mild hypotension). diltiazem and beta-blockade was started. the patient expericenced a 4 second pause in cardiac rhythm and relative hypotension and so was transferred back to the icu for rate control by diltiazem drip and beta blockade. over the following days her cardiac rate improved. she was transitioned to po diltiazem and beta-blockers were titrated to obtain adequate rate control. she remained in a-fib, and given the patient's desire to avoid anticoagulation, as well as her fall risk, it was decided by the surgical and cardiology teams not to have the patient on anti-coagulation except aspirin. of note, the patient does have a history of paroxysmal af, for which she had refused anticoagulation previously. this issue may be addressed by her pcp and cardiologist after discharge. the patient regained bowel function on [**11-20**] and was able to ambulate with assistance. she was advanced to a soft regular diet, which she tolerated well, however required significant encouragment to increase intake. on [**11-23**] it was noted that the patient's acute medical and surgical issues had been adequate dealt with and that her primary goals of care were that of physical rehabilitation. she was therefore discharged to [**hospital3 2558**] for acute rehabilitation on the afternoon of [**11-23**]. discharge instructions and follow up as listed above. splenectomy: performed during procedure of [**11-14**]. patient was administered spenectomy vaccines (pneumococcus, h-flu, and meningicoccus) prior to discharge. . cardiology was consulted for rapid/paroxysmal atrial fibrillation. . gi was consulted on [**11-4**] for gi bleed and recommended protonix, transfusion with goal hct >30 and egd and colonoscopy which were performed [**11-7**]. . pre-operative course issues: melena: the patient presented with 4-day h/o melena with diarrhea, lightheadiness and abdominal pain. this was c/w with upper gi bleeding even though ng lavage was negatvie in. her hct decreased to 25 and she received 2 units of prbc. her hct was stable throughout the hospital stay. she was not tachycardic or hypotensive. she had a edg done wich showed gastritis and a submucosal lesion in the mid-esophagus. colonoscopy revealed two polyps and a malignant appearing mass at 45 cm. there was no active bleeding identified. the pathology report came back as ademoma and one specimen . surgery was consulted who recommeneded an operation to remove the mass. she had a ct chest for staging and a pre-op evaluation by cardiology. . lightheadedness: the patients's lightheadiness started at the same time she noticed melena and diarrhea. this was most likley related to her anemia. her lightheadedness was unchanged throughout the pre-operative portion of her hospital stay. she had no orthostatics. . abdominal pain: the patient's abdominal pain was in the epigastric area. there was suspicion for pancreatitis given slightly elevated amylase and lipase, however there was no clinical or radiographic evidence. . chest pain: her chest pain has been chronic and did not appear to be cardiac in etiology. she had no doe, no radiation to arm or jaw. her cardiac enzyme x 1 was negative. stress test in [**2120**] was normal. her ekg was unchanged. she was on telemtry with no concerning changes. . cough: she has a recent hospitalization end of octover [**2123**] for bronchitis. her cough was improving. she was on albuterol nebs prn and anti-tussant prn. . chronic renal insufficiency: the patient's creatinine was 1.5 on admission, which was baseline. her cr was stable at 1.4-1.5 throughout the hospital stay. . diabetes mellitus type 2: her blood sugars were in the range of 80-200. she had mild hypoglycemic symptoms after being npo for her procedure. she received juice and d5w. she was stable throughout her hospital stay. she was on an insulin sliding scale. glyburide was held on admission and restarted on day of discharge. . htn: her blood pressure was controlled while holding on metoprolol and lasartan. medications on admission: - docusate sodium 100 mg [**hospital1 **] as needed for constipation. - aspirin 81 mg po daily - insulin lispro sliding scale - glyburide 2.5 mg po daily - losartan 50 mg po daiky - metoprolol succinate 25 mg po daily - fluticasone 50 mcg/actuation aerosol [**hospital1 **] - guaifenesin po q6h - doxercalciferol 0.5 mcg po daily - benzonatate 100 mg po tid - acetaminophen 650 mg q6h as needed. - pantoprazole 40 mg po q24h - menthol-cetylpyridinium 3 mg lozenge q6h as needed. - albuterol sulfate neb inhalation every 6 hours. - prednisone taper (40mgx2d, 30mgx2d, 15mgx2d, 10mgx2d, 5mgx2d) - started on [**2124-10-27**] discharge medications: 1. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed. 2. diltiazem hcl 30 mg tablet sig: one (1) tablet po qid (4 times a day). 3. metoprolol tartrate 25 mg tablet sig: three (3) tablet po tid (3 times a day). 4. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. aspirin, buffered 325 mg tablet sig: one (1) tablet po daily (daily). 7. glyburide 1.25 mg tablet sig: one (1) tablet po daily (daily). 8. amoxicillin-pot clavulanate 500-125 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 5 days. 9. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed. 10. albuterol sulfate 0.083 % (0.83 mg/ml) solution sig: one (1) inhalation q6h (every 6 hours) as needed. 11. insulin lispro 100 unit/ml solution sig: per flowsheet subcutaneous asdir (as directed). discharge disposition: extended care facility: [**hospital3 2558**] - [**location (un) **] discharge diagnosis: primary diagnosis 1. gastritis 2. anemia 3. adenocarcinoma of the colon 4. splenectomy secondary diagnoses: 1. chronic renal insufficiency 2. diabetes mellitus type 2 3. hypertension discharge condition: good. tolerating a soft regular diet. pain well controlled on oral medications. discharge instructions: -eat a soft diet while you are having difficulty with solid foods. incision care: -your steri-strips will fall off on their own. -you may shower, and gently wash surgical incision. -avoid swimming and [**known lastname 4997**]s until your follow-up appointment. -please call the doctor if you have increased pain, swelling, redness, or drainage from the incision site. 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. * 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. you were admitted to the hospital because you had evidence of blood in your stool and had abdominal pain and light-headedness. because your blood levels were low we gave you 2 units of blood which brought your blood levels back to your baseline. you had an endoscopy and a colonoscopy. based on the endoscopy you were diagnosed with mild gastritis (inflammation in the stomach) which was most likely the cause of your bleeding. in order to treat your gastritis we started you on a medication called protonix, which decreases the acid in your stomach which decreases irritation in the stomach. in the colonoscopy a 4cm mass was found in your colon. this mass was removed with the left part of your colon and it showed adenocarcinoma. . please take all your medications as prescribed, please go to all your follow up appointments as scheduled. followup instructions: dr. [**last name (stitle) **] (surgery), please call as soon as possible([**telephone/fax (1) 4336**] to make an appointment for 2-3 weeks from now. provider: [**first name11 (name pattern1) **] [**last name (namepattern4) 2847**], md phone:[**telephone/fax (1) 719**] date/time:[**2124-12-6**] 10:00 provider: [**name10 (nameis) **] [**last name (namepattern4) 1401**], m.d. phone:[**telephone/fax (1) 2386**] date/time:[**2125-1-23**] 10:40 opthomology: dr. [**first name8 (namepattern2) 33664**] [**name (stitle) **]. monday, [**2124-12-11**], at 9am. if you have any questions, please call [**telephone/fax (1) 28100**]. provider: [**first name8 (namepattern2) **] [**last name (namepattern1) 3310**], md phone:[**telephone/fax (1) 2226**] date/time:[**2125-3-9**] 9:30",1
99,"admission date: [**2113-2-2**] discharge date: [**2113-3-1**] date of birth: [**2039-8-6**] sex: f service: medicine allergies: aspirin / hydralazine / ace inhibitors / diovan attending:[**first name3 (lf) 689**] chief complaint: fever, chills major surgical or invasive procedure: central line placement (change over a wire) central line removal x 2 femoral line placement history of present illness: 73 y.o. female with h/o dmii, ischemic chf (ef ~30%), cad s/p nstemi and [**name prefix (prefixes) **] [**last name (prefixes) **] 2 to rca ([**11-26**]) c/b dye nephropathy and esrd (hospitalized [**2112-12-9**] - [**2112-12-28**]), on hd with recent tunneled line and fistula creation, who presented [**2113-2-2**], 1 day after leaving [**hospital3 **] (7 week stay, just discharged [**2113-2-1**]), with fevers to 104 c, rigors, and hypotension. she had just undegone placement of tunneled hd catheter (r ij) and also had av fistula placed ([**2113-1-26**]). ed course notable for initiation of vancomycin, levofloxacin and flagyl, and placement of femoral line. she was found to have a high grade mrsa bacteremia, with 7/8 bottles positive from [**2112-2-2**]. micu course notable for clearance of blood cultures on vancomycin, with hemodynamic stabilization. line changed over a wire, though catheter tip from original line then grew out mrsa. past medical history: hypercholesterolemia dm-2 htn cad - cath [**11-26**] with 3vd, s/p cypher [**name prefix (prefixes) **] [**last name (prefixes) **] 2 to rca. pulmonary htn chf (ef 30%), afib, esrd on hd severe lumbar spondylosis and spinal stenosis social history: denies tobacco, etoh, ivda. ambulates with walking assist device (walker), which she has required since 'being dropped by emts' prior to her surgical repair for spinal stenosis. uses also electronic wheelchair. family history: fhx: father died of cva at 64yo. mother died of mi @ 86yo. brother had cad. physical [**last name (prefixes) **]: gen: patient appears stated age, found lying flat in bed, talking with family, in nad heent: sclera anicteric, conjunctiva uninjected, perl, eomi, mmm, no sores in op neck: jvp difficult to assess, no lad, nl rom cor: rrr nl s1 s2 no m/r/g chest: clear to percussion and asculation abd: soft, nt/nd, +bs. no hsm appreciated. ext: no calf tenderness. 2+ edema to mid tibia. also with sacral edema. 2+dp, 1+ pt pulses neuro: ms [**first name (titles) **] [**last name (titles) **], cn ii-xii in tact, ue/le strength 5+ bilaterally, 2+ dtrs, toes [**name2 (ni) 14451**], nl cerebellar [**name2 (ni) **]. gait not tested. pertinent results: [**2113-2-2**] 10:22pm lactate-1.5 [**2113-2-2**] 10:22pm hgb-10.0* calchct-30 [**2113-2-2**] 09:27pm lactate-1.5 [**2113-2-2**] 08:05pm lactate-1.7 [**2113-2-2**] 07:04pm lactate-1.7 [**2113-2-2**] 06:33pm lactate-2.3* [**2113-2-2**] 06:00pm glucose-215* urea n-50* creat-3.5* sodium-138 potassium-5.1 chloride-102 total co2-27 anion gap-14 [**2113-2-2**] 06:00pm alt(sgpt)-4 ast(sgot)-12 ck(cpk)-67 alk phos-81 amylase-49 tot bili-0.3 [**2113-2-2**] 06:00pm lipase-27 [**2113-2-2**] 06:00pm ck-mb-notdone ctropnt-0.32* [**2113-2-2**] 06:00pm albumin-3.4 calcium-8.6 phosphate-3.1 magnesium-1.3* [**2113-2-2**] 06:00pm cortisol-30.0* [**2113-2-2**] 06:00pm crp-8.69* [**2113-2-2**] 06:00pm wbc-28.5* rbc-3.33* hgb-10.2* hct-29.5* mcv-89 mch-30.6 mchc-34.6 rdw-14.9 [**2113-2-2**] 06:00pm neuts-73* bands-25* lymphs-0 monos-1* eos-0 basos-0 atyps-0 metas-0 myelos-0 young-1* [**2113-2-2**] 06:00pm hypochrom-1+ anisocyt-1+ poikilocy-1+ macrocyt-1+ microcyt-1+ polychrom-normal ovalocyt-1+ teardrop-1+ [**2113-2-2**] 06:00pm plt count-178 [**2113-2-2**] 06:00pm urine color-straw appear-clear sp [**last name (un) 155**]-1.021 [**2113-2-2**] 06:00pm urine blood-lg nitrite-neg protein-500 glucose-100 ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg [**2113-2-2**] 06:00pm urine rbc-[**11-12**]* wbc-0-2 bacteria-mod yeast-none epi-[**6-2**] [**2113-2-2**] 06:00pm urine amorph-mod [**2113-2-2**] 04:12pm type-[**last name (un) **] [**2113-2-2**] 04:12pm lactate-2.2* [**2113-2-2**] 12:35pm urine color-straw appear-clear sp [**last name (un) 155**]-1.020 [**2113-2-2**] 12:35pm urine blood-mod nitrite-neg protein-500 glucose-250 ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg [**2113-2-2**] 12:35pm urine rbc-[**2-25**]* wbc-0-2 bacteria-few yeast-none epi-0-2 [**2113-2-2**] 12:35pm urine granular-<1 hyaline-<1 [**2113-2-2**] 12:35pm urine amorph-few [**2113-2-2**] 12:01pm lactate-2.7* [**2113-2-2**] 11:50am glucose-196* urea n-48* creat-3.4*# sodium-141 potassium-5.4* chloride-102 total co2-29 anion gap-15 [**2113-2-2**] 11:50am alt(sgpt)-6 ast(sgot)-11 ck(cpk)-46 alk phos-98 amylase-60 tot bili-0.4 [**2113-2-2**] 11:50am ctropnt-0.11* [**2113-2-2**] 11:50am ck-mb-notdone [**2113-2-2**] 11:50am albumin-3.8 calcium-9.0 phosphate-3.6 magnesium-1.4* [**2113-2-2**] 11:50am wbc-19.9*# rbc-3.64*# hgb-11.2*# hct-32.4* mcv-89 mch-30.6 mchc-34.5 rdw-14.7 [**2113-2-2**] 11:50am neuts-92* bands-5 lymphs-2* monos-1* eos-0 basos-0 atyps-0 metas-0 myelos-0 [**2113-2-2**] 11:50am hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal [**2113-2-2**] 11:50am plt smr-normal plt count-159 [**2113-2-2**] 11:50am pt-13.7* ptt-25.4 inr(pt)-1.2 brief hospital course: a/p: 73 yo f with cad, chf, esrd, htn, hyperlipidemia, spinal stenosis who p/w high grade mrsa bacteremia after recent placement of hd line. (1) mrsa bacteremia - initial source for infection was likely the tunneled hd catheter. the catheter was removed, and a temporary line was placed over a wire at the same site initially. however, as her blood cultures failed to clear, the temporar hd line was removed [**2113-2-7**], and a new l-sided temporary hd line was placed. nonetheless, her blood cultures remained positive, despite apparently therapeutic levels of vancomycin, with worsening leukocytosis, and gentamycin was added for synnergy. tte and tee did not reveal evidence of endocarditis, though chest ct suggested probable mrsa pneumonia. diagnostic thoracentesis was performed [**2-10**] and negative for infection. us of the r sided arm and neck veins was negative for clot as a source of infection. blood cultures remained positive until [**2-12**]. on [**2-15**] she was started on daptomycin iv 6 mg/kg q 48 hours and on [**2-16**] the temporary dialysis catheter was changed over a wire and the tip cultured with no growth. ct of the entire spine with contrast and of the torso was also performed with the following results: ct results [**2-16**]: * chest and abdomen * 1. no discrete abscesses or abnormal fluid collections are seen aside from right-sided pleural effusion and associated atelectasis. 2. markedly distended gallbladder, with gallstones. this can be seen in the setting of prolonged fasting, although if there are symptoms referrable to this region, right upper quadrant ultrasound could be performed. 3. marked coronary artery calcifications. 4. equivocal soft tissue filling defect adjacent to the left ij central venous catheter, which could represent adherent thrombus at the tip. note that ct is neither sensitive nor specific for detection of adherent thrombus. 5. two or three areas of focal consolidation in subpleural locations within the right upper lobe as described above. * spine * ct of the cervical spine: evaluation of the soft tissue windows demonstrates no evidence of abnormal fluid collection or bony destruction. there is no cervical lymphadenopathy present. there is a 7 mm low density right thyroid nodul, which can be evaluated by ultrasound if clinically indicated. also, right-sided pleural effusion is seen, indeterminately evaluated on this examination. evaluation of the coronally and sagittally reformatted images demonstrates appropriate alignment of the cervical spine, without significant abnormal soft tissue swelling. degenerative narrowing of the disc spaces at c6-7, c7-t1, are seen without significant facet changes at these levels. note is made of marked vascular calcifications involving the cavernous internal carotid arteries as well as a left-sided internal jugular central venous catheter. ct of the thoracic spine: scans are marred by artifact and of limited diagnostic quality. no fracture is identified. alignment is normal. the vertebral body heights are normal, however there is marked diffuse disc space narrowing. there are a few small areas of decreased attenuation in somee of the vertebral bodies. this is of uncertain nature. no endplate cortical destruction is seen. vertebral bodies have bridging osteophytes. there is poor visualization of the intraspinal structures. there are no gross abnormalities observed in the perivertebral soft tissues. there is a moderate-sized right pleural effusion. ct lumbar spine: again seen is grade 1 anterolisthesis of l4 in relation to l5 and new grade 1 to 2 anterolisthesis of l5 on s1. the remaining vertebral bodies are well aligned. there is vacuum disc phenomenon at l5-s1. there is disc space narrowing at t12-l1, l1-l2, l2-l3, likely l3-l4, l4-l5, and l5-s1. again noted are pedicle screws and posterior rods transfixing l3 through l5. there is associated laminectomy at these vertebral levels. the neural foramina in the lower lumbar region are difficult to assess secondary to hardware artifact. no vertebral fractures or hardware loosening is appreciated. there are no destructive changes of the endplates to indicate osteomyelitis. the prevertebral soft tissues appear morphologically normal. the posterior soft tissues are obscured by artifact from the fusionhardware. the intraspinal contents are not well seen. she was unable to fit into an mri scanner for evaluation of possible osteomyelitis or epidural abscess given persistent postitive cultures and back pain. ct scan was done as above and plan for open mri as an outpatient. she remained culture negative despite daily surveillance cultures until [**2-20**]. she was switched back to vancomycin. from [**2-13**] to [**2-27**] her blood cultures (collected at each dialysis) were negative. should they have vecome positive again, plan was to pursue a white blood cell tagged scan to identify a source of infetion. due to mechanical falure of the line her dialysis catheter was changed over a wire on [**2-21**] and then a tunneled catheter was placed [**2-24**]. she has been awaiting placement with no events occurring since [**2-24**]. (2) cri/esrd - upon admission, it was hoped that the patient's renal function had recoverd to the extent that hd could be delayed for several months. however, attempts to achieve fluid balance with diuretics, including lasix and metalozone, were unsuccessful, and given worsening cr, the decision was made to proceed with hemodialysis. phoslo was titrated. she has been on t/th/saturday dialysis since admission. ultrafiltration has been pursued to remove fluid. on one occasion [**2-24**], she experienced hypotension with nausea after dialysis. the hypotension responded to 1l fluids. given this was like her presentation with nstemi, a set of cardiac enzymes was checked (troponin still trending down from previous event) and an ekg (no changes). the nausea resolved with the hypotension. likely etiology was too much fluid removal with ultrafiltration. (3) anemia - patient required several units of prbc transfusions, and was started on erythropoietin 8000u thrice weekly. this is most likely because of chronic kidney disease combined with extensive phlebotomy here (many many blood cultures and chem 10, cbc daily until [**2-21**] when they were changed to dialysis days only). (4) chf - patient noted to have mildly decompensated heart failure,likely secondary to volume overload while dialysis was on hold. she was not started on an ace or [**last name (un) **], given prior adverse reactions, but was maintained on low-dose beta-blocker. (5) back pain - no clear etiology evident on ct scan, doubt abscess or osteomyelitis. this is may be from anterolisthesis of l5 on s1 as seen in ct scan. (6) a-fib - continued b-blocker. re-starting anticoagulation with coumadin, please maintain inr between 2 and 2.5. on aspirin/plavix. (7) cad - continued aspirin, plavix, statin, b-blocker. medications on admission: 1. citalopram hydrobromide 20 mg tablet sig: one (1) tablet po daily (daily). 2. gabapentin 300 mg capsule sig: one (1) capsule po daily (daily). 3. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. atorvastatin calcium 40 mg tablet sig: two (2) tablet po daily (daily). 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 7. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po daily (daily). 8. linezolid 600 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 3 days: last dose is [**2112-12-31**]. 9. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 10. heparin sodium (porcine) 5,000 unit/ml solution sig: one (1) injection injection tid (3 times a day). 11. trazodone hcl 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. 12. calcitriol 0.25 mcg capsule sig: one (1) capsule po every other day (every other day). 13. calcium acetate 667 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). 14. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours). 15. codeine-guaifenesin 10-100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed. 16. albuterol sulfate 0.083 % solution sig: one (1) neb inhalation every 4-6 hours as needed for sob. 17. insulin regimen nph regimen of 4 units of nph at breakfast and 6 units and dinner with sliding scale which is attached. thank you. discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 4. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po daily (daily). 5. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed. 6. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 7. gabapentin 300 mg capsule sig: one (1) capsule po daily (daily). 8. citalopram hydrobromide 20 mg tablet sig: one (1) tablet po daily (daily). 9. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day). 10. zolpidem tartrate 5 mg tablet sig: 1-2 tablets po hs (at bedtime). 11. epoetin alfa 4,000 unit/ml solution sig: two (2) injections injection qmowefr (monday -wednesday-friday): for a total of 8000 unit sc qmowefr . 12. calcium acetate 667 mg tablet sig: two (2) tablet po tid w/meals (3 times a day with meals). 13. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 14. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 15. magnesium oxide 400 mg tablet sig: one (1) tablet po daily (daily). 16. senna 8.6 mg tablet sig: two (2) tablet po bid (2 times a day). 17. tramadol hcl 50 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 18. vancomycin hcl 10 g recon soln sig: one (1) gram intravenous prn (as needed) as needed for for level less than 15, dosed at dialysis. discharge disposition: extended care facility: [**hospital **] medical center - [**hospital1 3597**] discharge diagnosis: sepsis mrsa bacteremia chf cad hypertension hypotension end stage renal disease on hemodialysis anemia atrial fibrillation hyperlipidemia discharge condition: fair discharge instructions: please take all of your medications as instructed. please return to the hospital or call you doctor if you have any further fever, chills, persistently low blood pressures that do not respond to fluids, racing heart or other symptoms. followup instructions: 1. please follow up with your primary care doctor ([**first name4 (namepattern1) **] [**last name (namepattern1) 410**] [**telephone/fax (1) 1144**]) one to two weeks after your discharge from the rehabilitation facility. 2. you have an appointment with dr. [**first name4 (namepattern1) **] [**last name (namepattern1) 6173**] of the infectious disease department at [**hospital1 1170**] on tuesday, [**3-21**] at 11:00 am. his office is located in the [**hospital **] medical office building at 110 [**location (un) 33316**] st. next to the medical center [**hospital ward name 517**]. phone:[**telephone/fax (1) 457**].",1
100,"admission date: [**2126-3-11**] discharge date: [**2126-3-26**] date of birth: [**2058-1-29**] sex: f service: medicine allergies: cephalosporins / vancomycin / codeine attending:[**first name3 (lf) 2474**] chief complaint: dysuria, abdominal pain major surgical or invasive procedure: percutaneous ct scan guided drainage of abdominal fluid. history of present illness: patient is a 68 yo f, h/o cervical ca, radiation cystitis, radiation colitis, frequent line infections, recurrent utis who presented after developing acute on chronic severe abdominal pain. four days prior to admission, patient woke with severe abdominal pain that was worsened with movement. she had some dysuria in the days prior. she also complained of nausea and vomiting. her abdominal pain was worsened by movement. she denied fevers or chills. . she was brought by ambulance to an outside hospital. there she had a ct of her abdomen which was notable for mild ascites, but no acute process. she was mildly hypotensive to sbp of 90s and was given 3 l ns. given levofloxacin/flagyl. she was transferred to the [**hospital1 18**] ed. on arrival t 100.8, hr 107, bp 100/71. soon thereafter sbp dropped to the 70s and she was bolused a total 5l ns. her ostomy output was heme negative. u/a showed gross blood and + wbc. she was given one dose of meropenem 500mg iv, as this is what she was discharged on previously. her pain was also treated with tylenol and dilaudid. she became mildly hypotensive with dilaudid. pt was then transfer to the micu her vs were t 98, 120/51, 15, 99/ra. . on arrival to the icu, she again become hypotensive and required levophed. she also recieved one unit of prbcs for hct of 22. she was continued on meropenem for presumed urosepsis, and had received a total of 8l of iv fluids while in the icu. she was then transferred to the floor after she stabilized on [**3-13**]. . the morning of [**3-14**], she was noted to be in marked respiratory distress. her oxygen saturation at times dropped to 80% on non-rebreather, and was noted to be hypertensive into the 160s systolic. she was given 20mg lasix x 2, her usual dose of dilaudid and hydralazine without marked improvement, and the micu resident was called. examination demonstrated bilateral crackles and jvp elevated to the angle of the mandible. cxr demonstrated marked pulmonary edema. she was given nitroglycerin sl and transferred to the icu for possible initiation of bipap. . when she arrived in the icu, her respiratory status had markedly improved and she denied any shortness of breath or chest pain. she continued however to have abdominal pain. past medical history: 1. cervical ca s/p tah/xrt s/p hysterectomy [**2096**] with recurrence in [**2097**] 2. radiation cystitis 3. urinary retention; straight catheterization ~8x per day 4. r ureteral stricture -- c/b recurrent infections -- s/p right nephrectomy ([**2123**]) 5. recurrent utis: (klebsiella (amp resistant) and enterococcus (levo resistant) 6. short gut syndrome since [**2109**] s/p colostomy from radiation enteritis. 7. osteoporosis 8. hypothyroidism 9. migraine ha 10. depression 11. fibromyalgia 12. chronic abdominal pain syndrome 13. multiple admits for enterococcus, klebsiella, [**female first name (un) **] infections 14. dvt / thrombophlebitis from indwelling central access 15. lumbar radiculopathy 16. multiple prior picc line / hickman infections -- see multiple surgical notes [**2115**] to date 17. h/o sbo followed by surgery [**33**]. h/o stemi [**2-20**] takotsubo cm, with clean coronaries on cath in [**4-27**]. ef down to 20% in setting of illness, but ef recovered to 55-60%, in setting of klebsiella pna. 19. hyponatremia: previously attributed to hctz use social history: she lives with her husband in an [**hospital3 4634**] [**last name (un) **]. she reports a 80 py smoking history but quit 18 years ago. denies alcohol or drugs. she walks with a walker but has a history of frequent falls. independent of adls. family history: father with etoh abuse, cad. [**last name (un) **] with renal ca, cad. 3 healthy children. physical exam: admission exam: gen: pleasant, comfortable, nad heent: perrl, eomi, anicteric, mmm, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules resp: cta b/l with good air movement throughout cv: rr, s1 and s2 wnl, no m/r/g abd: nd, +b/s, soft, nt, no masses or hepatosplenomegaly ext: no c/c/e skin: no rashes/no jaundice/no splinters neuro: aaox3. cn ii-xii intact. . discharge exam: vs: t 98.8 , bp 120/56 , p 81 , rr 16 , o2 99 % on ra, gen: thin woman in nad heent: normocephalic, anicteric, op benign, mm appear dry cv: rrr, no m/r/g; there is no jugular venous distension appreciated, dp pulses 2+ bilaterally pulm: expansion equal bilaterally, but overall decreased air movement, worst at right lung field abd: soft, nd, bs+, ostomy bag in place. mild tenderness to palpation extrem: warm and well perfused, no c/c/e neuro: a and ox3, strength 3/5 in lower extremities, [**4-23**] in upper extremities psych: pleasant, cooperative. pertinent results: admission labs: [**2126-3-11**] 08:45pm blood wbc-7.6# rbc-3.20* hgb-9.4* hct-28.5* mcv-89 mch-29.2 mchc-32.9 rdw-13.1 plt ct-175 [**2126-3-11**] 08:45pm blood neuts-93.8* lymphs-3.5* monos-2.6 eos-0 baso-0.1 [**2126-3-11**] 08:45pm blood glucose-93 urean-17 creat-1.4* na-134 k-5.2* cl-106 hco3-17* angap-16 [**2126-3-11**] 08:45pm blood alt-16 ast-26 ld(ldh)-145 ck(cpk)-203* alkphos-81 totbili-0.2 [**2126-3-11**] 08:45pm blood lipase-27 [**2126-3-11**] 08:57pm blood lactate-3.2* . icu labs: [**2126-3-15**] 04:00pm blood ck-mb-4 ctropnt-<0.01 [**2126-3-16**] 04:28am blood ck-mb-3 ctropnt-<0.01 probnp-2468* [**2126-3-17**] 02:23pm blood anca-negative b [**2126-3-17**] 02:23pm blood [**doctor first name **]-negative [**2126-3-17**] 02:23pm blood crp-188.2* [**2126-3-17**] 02:23pm blood aspergillus galactomannan antigen-pnd [**2126-3-17**] 02:23pm blood b-glucan-pnd . discharge labs: [**2126-3-26**] 06:00am blood wbc-3.6* hgb-7.4* hct-22.5* mcv-87 mch-28.6 mchc-32.8 rdw-13.2 plt ct-565 [**2126-3-26**] 06:00am reticulocyte count, manual 1.7* [**2126-3-26**] 06:00am ldh 119 t.bili 0.1 direc bili 0.1 indirect bili 0.0 [**2126-3-26**] 05:44am blood glucose-86 urean-36 creat-1.2 na-136 k-4.5 cl-105 hco3-22 [**2126-3-26**] 05:44am blood calcium-9.6* phos-4.8 mg-2.1 . microbiology: [**2126-3-11**] blood cx: negative [**2126-3-11**] urine cx: 10,000-100,000 organisms/ml. alpha hemolytic colonies consistent with alpha streptococcus or lactobacillus sp. [**2126-3-12**] stool cx: negative [**2126-3-12**] blood cx: negative [**2126-3-16**] urine legionella ag: negative [**2126-3-18**] influenza swab: negative . imaging: [**2126-3-11**] cxr: in comparison with the study of [**2-11**], there is some increased opacification at the left base, which does not silhouette the hemidiaphragm or left heart border. although this could conceivably represent a region of pneumonia, it more likely reflects artifact of soft tissues pressed against the cassette. no evidence of vascular congestion or pleural effusion. tip of the central catheter again lies in the mid-to-lower portion of the svc. . [**2126-3-12**] ct abdomen/pelvis w/ con: 1. new moderate ascites and small bilateral pleural effusions. no evidence of abscess or pyelonephritis. 2. unchanged fullness of the left renal pelvis, likely due to upj obstruction. 3. stable moderate common bile duct dilation in this patient who is post-cholecystectomy. . [**2126-3-16**] ct chest w/o con: 1. extensive fibrotic changes and ground-glass opacity suggestive of pneumonitis such as hypersensitivity pneumonitis, drug toxicity or nsip. 2. no evidence of edema or pneumonia. . [**2126-3-18**] echo: the left atrium and right atrium are normal in cavity size. the estimated right atrial pressure is 0-10mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). the estimated cardiac index is normal (>=2.5l/min/m2). the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: normal biventricular cavity sizes with preserved global and regional biventricular systolic function. mild aortic regurgitation. mild mitral regurgitation. compared with the prior study (images reviewed) of [**2125-10-30**], mild mitral regurgitation is now seen. . [**2126-3-19**] chest x-ray: in comparison with the study of [**3-18**], there has been decrease in the diffuse bilateral pulmonary opacifications, consistent with improving pulmonary edema or hemorrhage. blunting of the costophrenic angle on the right persists consistent with a small effusion. increasing opacification at the left base is consistent with pleural effusion and some volume loss. central catheter remains in place. . [**2126-3-21**] kub: dilated loops of bowel in the left mid abdomen up to 4.8 cm which raise concern for small-bowel obstruction. ct provides more specific information if clinical concern remains. . [**2126-3-21**] kub: supine and upright abdominal radiographs were obtained. a dilated loop of bowel in the left lower quadrant measures 4.8 cm and is essentially unchanged in four hours. surgical clips project over the mid abdomen and pelvis. a calcified right breast implant is seen. dilated bowel loop remains concerning for small-bowel obstruction. . [**2126-3-22**] ct abdomen:1. multiple intra-abdominal fluid collections, with rim enhancement and pockets of air, highly suspicious for abscess. 2. interval development of marked left hydronephrosis. 3. status post right nephrectomy. appearance of fluid-filled tubular structure at the expected location and course of the right ureter. if the patient did not have right ureteral resection, this could represent a urine-filled right ureteral stump. recommend clinical correlations. 4. thickened, diffuse bladder wall, likely radiation change such as radiation cystitis. 5. no bowel obstruction. oral contrast has reached the rlq ileostomy bag. . [**2126-3-25**] abd us:1. a small subhepatic fluid collection measuring 4.5 cm. previously seen right paracolic gutter and pelvic fluid collections are not well visualized. please note that ultrasound is less sensitive for detecting loculated intra-abdominal fluid collections. 2. stable appearance of the mild intra- and extra-hepatic biliary dilatation. 3. moderate left hydroureteronephrosis, slightly improved since the prior study. . at time of discharge, intraabdominal fluid culture pending (prelim result no growth to date). brief hospital course: micu course: [**date range (1) 70244**] # sepsis of likely urinary origin: upon presentation to [**hospital1 18**] on [**3-11**], had blood pressure drop to 70s sytolic. she was given 5l ivf in ed and transferred to micu. cxr was unrevealing. u/a showed increased leuks and wbc on urine micro. was empirically started on meropenem in micu given that patient had recently been on carbapenems for a uti in end of 1/[**2126**]. in micu her bp was intially stable and then fell and patient was started on norepinephrine, which she remained on for approximately 17 hours on [**3-12**]. given patient's severe abdominal pain, received a ct abd/pelvis in the ed which showed moderate ascites, though no other acute changes. surgery consult was called and felt that there was no acute surgical intervention indicated and followed the patient's course in the micu. we also trended patient's lactate level, which was 3.2 at presentation and trended down to 1.3 with fluid resuscitation. checked cdiff toxin, which was negative. iv team was called to assist in managment of patient's tunneled double lumen catheter and they suggested ethanol dwells between tpn infusions in order to prevent line infection. blood cultures from [**3-11**] and [**3-12**] were negative. . # abdominal pain: pain with severe abdominal pain upon presentation. we reassured after ruling out acute intra-abdominal process with ct scan and serial exams. given frequent (q1hour) iv dilaudid requirements on morning of [**3-13**], pain service consult was called; however, prior to pain service seeing patient her pain improved to point that dilaudid could be given less frequently. was felt that we had been behind on pain control after sleeping overnight, possible due to held doses of gabapentin. she was continued on methadone, dilaudid, and gabapentin. . # anemia: hct was found to be 22, pt was transfused 1 unit of prbcs. post-transfusion hct was 26.9. . medicine floor course: [**date range (1) 32116**]: patient was called out from the micu on [**2126-3-13**] after she had been normotensive for 24 hours without pressors. she had a new oxygen requirement (94% on 4l) thought [**2-20**] volume overload (8 l + for los). overnight, she was hypertensive to 188/80. in the morning she was found to be hypoxic to 81% on 4l. she was put on a non-rebreather with intermittent improvement of her oxygen sats to low 90s but would then drop to low 80s. she was also given iv lasix 20 mg x 2 and she put out 2 l in 2 hours. her blood pressure was treated with hydralazine 20 mg iv x1 and sl nitro. despite these interventions she was still hypoxic in the 80s on a non-rebreather and was transferred back to the micu for positive pressure ventilation and aggressive diuresis. . micu course: [**date range (1) 97780**]: cxr was c/w volume overload, likely from fluid resuscitation she received in the micu. she was diuresed with iv lasix and started on azithromycin for atypical pneumonia coverage. ct chest performed later revealed extensive fibrotic changes and ground-glass opacities suggestive of pneumonitis such as hypersensitivity pneumonitis, drug toxicity, or nsip. pneumonitis workup was initiated. esr =83, crp = 188.2, [**doctor first name **], anca, beta-glucan, and galactomannan were all negative. she was stable and was transferred to the floor for further evaluation. . medicine floor course: [**date range (1) 20494**]: pt was stable and continued to improved. active issues: . # hypoxemia/pulmonary infiltrates: oxygenation gradually improved and pt was weaned off oxygen supplement gradually. etiology of infiltrates was unclear, possibilities included [**name (ni) **] and medication-induced lung toxicity. pt received 1 course of azithromycin for possible atypical pneumonia. her flu and legionella screenings were negative. she was weaned off o2 and mantained 95%+ saturation on room air at the time of discharge. . # urosepsis: pt remained hemodynamically stable on the floor. she received meropenem for total of 7 days ([**date range (1) 28666**]). she remained without urinary complaints. pt was given hyoscyamine for bladder spasm pain. . #anemia: the patients hematocrit trended down throughout her hospitalization from around 27 to a low of 22. her baseline over the last few months has been 25-28. this was attributed to her ongoing inflammation secondary to her radiation enteritis and cystitis, although the precise etiology remains unclear, and infection and myelodysplasia should be considered as well. her manual reticulocyte count was found to be 1.7 (corrected 0.53), indicating insufficient marrow response. her ostomy output was found to be guiac negative and her c+ ct scan of the abdomen and pelvis demonstrated no evidence of active bleeding. hemolysis labs demonstrated no evidence of ongoing hemolytic process, however corrected retic count was low. this can be due to illness or medication suppression. recent iron studies were all within normal limits. pt was instructed to follow up with primary care physician about this issue, with repeat hct/reticulocyte count and further workup as needed. . # abdominal pain/fluid collections: the patient had known chronic abdominal pain related to cervical cancer and radiation complications. c. diff was been negative. we continued her home medication (methadone and oxycodone), and added dilaudid. pt was able to eat and drink, and did not have any vomiting. she was evaluated with kub for possible obstruction, which showed dilated loops of bowel. ct of abdomen demonstrated multiple fluid collections, enlarged fluid filled bladder, l hydronephrosis, and a dilated fluid filled ureteral stump. urology was consulted, and a foley was placed for decompression. when the patient was taken for ct-guided drainage of the collections, the collections had almost completely disappeared, potentially related to decompression from the foley catheter. fluid from the remaining collection was sampled and sent for culture and analysis, which demonstrated no bacteria and a creatinine of 1.8 (not consistent with urinoma). repeat ultrasound demonstrated interval resolution of the previoulsy noted hydronephrosis and stable appearance of the fluid collections compared to the most recent ct scan. . chronic issues: . # ckd: pt cr remained at her her baseline, and no new acute issues. . # short gut syndrome: we continued pt's tpn and she was also followed by the nutritionist while she was in the hospital. . # anxiety/depression: we continued pt's home meds (alprazolam, fluoxetine). . # chronic pain/fibromyalgia: we continued the pt's home meds (gabapentin, methadone). . # hypothyroidism: we continued the pt's home med (levothyroxine). . # osteoporosis: we continued the pt's home med (vitamin d, calcium). . #htn: we restarted pt's lisinopril on [**3-19**] after her blood pressure returned to its chronically high level. medications on admission: 1. alprazolam 0.25 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)) as needed for insomnia. 2. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po 5x/week (mo,tu,we,th,fr). 3. fexofenadine 60 mg tablet sig: one (1) tablet po daily (daily). 4. fluoxetine 20 mg capsule sig: one (1) capsule po tid (3 times a day). 5. gabapentin 300 mg capsule sig: one (1) capsule po qid (4 times a day). 6. levothyroxine 50 mcg tablet sig: one (1) tablet 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). 8. pilocarpine hcl 5 mg tablet sig: one (1) tablet po q4h (every 4 hours). 9. methadone 5 mg tablet sig: one (1) tablet po qid (4 times a day). 10. ertapenem 1 gram recon soln sig: one (1) gram intravenous once a day for 6 days. [**month/day (4) **]:*7 grams* refills:*0* 11. oxycodone 5 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain. 12. pyridium 100 mg tablet sig: one (1) tablet po three times a day as needed for pain. 13. ondansetron 8 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every eight (8) hours as needed for nausea. 14. lisinopril 10 mg tablet sig: one (1) tablet po once a day. [**month/day (4) **]:*30 tablet(s)* refills:*2* 15. vitamin b-12 1,000 mcg/ml solution sig: one (1) injection injection once a month. 16. darifenacin 15 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po at bedtime. 17. hyoscyamine sulfate 0.125 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po four times a day as needed for bladder spasm. 18. ativan 0.5 mg tablet sig: one (1) tablet po once a day as needed for anxiety. 19. vivelle-dot 0.0375 mg/24 hr patch semiweekly sig: one (1) transdermal semiweekly. 20. zolmitriptan 2.5 mg tablet sig: one (1) tablet po once a day as needed for headache. 21. calcium carbonate 200 mg (500 mg) tablet, chewable sig: one (1) tablet, chewable po twice a day. 22. fioricet 50-325-40 mg tablet sig: one (1) tablet po three times a day as needed for headache. 23. optics mini drops sig: 1-2 drops once a day. 24. metrogel 1 % gel sig: one (1) topical twice a day. 25. ethanol 70% catheter dwell (tunneled access line) sig: two (2) ml once a day: 2 ml dwell daily not for iv use. to be instilled into central catheter port (both ports) for local dwell. for 2 hour dwell following tpn. aspirate and follow with normal flushing. discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 2. gabapentin 300 mg capsule sig: one (1) capsule po q12h (every 12 hours). 3. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. methadone 5 mg tablet sig: one (1) tablet po qid (4 times a day). 6. lorazepam 0.5 mg tablet sig: one (1) tablet po daily (daily) as needed for anxiety. 7. butalbital-acetaminophen-caff 50-325-40 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for headache. 8. fluoxetine 20 mg capsule sig: one (1) capsule po bid (2 times a day). 9. hyoscyamine sulfate 0.125 mg tablet, sublingual sig: one (1) tablet, sublingual sublingual qid (4 times a day) as needed for bladder spasm. 10. calcium carbonate 200 mg (500 mg) tablet, chewable sig: one (1) tablet, chewable po bid (2 times a day). 11. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 12. maalox advanced oral 13. vivelle-dot 0.0375 mg/24 hr patch semiweekly sig: one (1) transdermal 2xweek (). 14. salagen 5 mg tablet sig: one (1) tablet po qid (4 times a day). 15. lisinopril 10 mg tablet sig: three (3) tablet po daily (daily). 16. heparin flush (10 units/ml) 2 ml iv prn line flush tunneled access line (e.g. hickman), heparin dependent: flush with 10 ml normal saline followed by heparin as above daily and prn per lumen. 17. ethanol (ethyl alcohol) 98 % solution sig: two (2) ml injection daily (daily). 18. oxycodone 5 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 19. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. [**month/day (4) **]:*30 tablet(s)* refills:*0* 20. clotrimazole 10 mg troche sig: one (1) troche mucous membrane qid (4 times a day). discharge disposition: extended care facility: [**hospital6 85**] - [**location (un) 86**] discharge diagnosis: urosepsis, anemia, pulmonary infiltrates, hydronephrosis, abdominal fluid collections discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - with assistance. discharge instructions: dear ms. [**known lastname 13275**], . it was a pleasure taking care of you at [**hospital1 827**]. you were admitted for a severe infection of the urinary tract, anemia, low blood pressure and shortness of breath. . -for your urinary tract infection, you were given a course of iv antibiotics and your infection resolved. . -for your low blood pressure, you were given iv fluids and medications to help maintain your blood pressure initially. your low blood pressure was related to your urinary tract infection and improved as this issue improved. after you returned to your baseline blood pressure (high), we restarted your blood pressure medication. . -for your anemia, you were transfused 1 unit of packed red blood cells. you should follow up regarding this issue with your primary care doctor as an outpatient. . -for your shortness of breath, you were given oral antibiotics, supplementary oxygen and diuretics, and you improved. we think that your shortness of breath may have been related to an adverse reaction to a blood transfusion that you received. you will follow up as outpatient at the pulmonary clinic (see below). . -for your abdominal pain, we obtained a ct scan which initially showed multiple fluid collections in your abdominal cavity. these collections resolved spontaneously following placement of a foley catheter, and so we suspect that they were related to your bladder. we took you to interventional radiology to sample fluid from one of these collections, and found no evidecne of infection. you were also followed by urology, who recommended keeping the foley in place until you have an appointment with them in 2 weeks. . we made the following changes to your medications: changed oxycodone 5mg 1-2 tablets by mouth every 6 hours to po dilaudid 2mg 1-2 tablets every 4 hours as needed for pain. . started hyocyamine 0.125mg sl every 6 hours as needed for bladder spasm started clotrimazole 1 troc by mouth 4 times a day. followup instructions: name: [**last name (lf) 6692**], [**name8 (md) 41356**] np specialty: urology address: [**street address(2) **], ste#58 [**location (un) 538**], [**numeric identifier 7023**] phone: [**telephone/fax (1) 16240**] appointment: thursday [**4-11**] at 1:30pm radiology department: wednesday [**2126-4-17**] at 11:45 am building: [**hospital6 29**] [**location (un) 861**], [**telephone/fax (1) 327**] campus: east best parking: [**hospital ward name 23**] garage ** an order has been placed for you to have a chest x-ray prior to your pulmonary appointments department: pulmonary function lab when: wednesday [**2126-4-17**] at 12:40 pm with: pulmonary function lab [**telephone/fax (1) 609**] building: [**hospital6 29**] [**location (un) **] campus: east best parking: [**hospital ward name 23**] garage department: medical specialties when: wednesday [**2126-4-17**] at 1 pm with: [**first name4 (namepattern1) **] [**last name (namepattern1) **], m.d. [**telephone/fax (1) 612**] building: [**hospital6 29**] [**location (un) **] campus: east best parking: [**hospital ward name 23**] garage department: pft when: wednesday [**2126-4-17**] at 1 pm please call your primary care physician when you leave rehab for an appointment. [**first name11 (name pattern1) **] [**last name (namepattern4) 2477**] md, [**md number(3) 2478**] completed by:[**2126-3-27**]",1
101,"admission date: [**2108-7-31**] discharge date: [**2108-8-10**] date of birth: [**2042-6-25**] sex: f service: medicine allergies: mevacor / bactrim / dilantin kapseal / naprosyn / clindamycin / percocet / quinine / levofloxacin / penicillins / vicodin / latex gloves / morphine / optiflux attending:[**first name3 (lf) 1973**] chief complaint: melena major surgical or invasive procedure: 1. tunnelled cath placement 2. upper gi endoscopy 3. bone scan 4. skin biopsy history of present illness: mrs [**known lastname 1968**] is a 66 yo woman with esrd on hd, c/b calciphylaxis, afib on [**known lastname **], who c/o generalized weakness x2-3 wks now presents with tarry stools and hypotension. pt states that she had a large, black, tarry bm this morning, then went to [**known lastname 2286**] today and was feeling weaker than usual, requiring help with ambulating. she was hypotensive and inr was found to be elevated to 19, therefore she was referred to the ed for further evaluation. pt [**known lastname **] other symptoms including fever, however does state that she has had watery diarrhea 4x/day for the last several days, also c/o decreased appetite. she has also been feeling lightheaded. she [**known lastname **] changes in her diet recently and does not think that she could have accidentally overdosed on her [**known lastname **]. . in the ed, initial vitals were: 97.5 104 80/23 18 100% 4l (baseline 3l), however sbps range from 70-90s at baseline and the pt was mentating well. exam was notable for melanotic, guiac + stool, gastric lavage showed no evidence of bleeding. labs were notable for a crit of 20.2, inr was 19.2. she was given pantoprazole, dilaudid, 2u prbcs, 2 u ffp, 2 u fluids. 2 18 gauge periph ivs were placed. chest xray was without effusion or consolidation, l-sided [**known lastname 2286**] line in place. she was seen by renal and gi in the ed who will continue to follow on the floor. . on the floor, pt is alert, oriented, c/o pain in legs, otherwise asmptomatic. . ros: (+) per hpi, also c/o chest congestion, worse doe for the last [**3-1**] wks, pt only able to ambulate a few feet before becoming sob. she had one epidode of vomiting after taking meds last night. (-) [**month/day (3) 4273**] fever, chills, night sweats, recent weight loss or gain. [**month/day (3) 4273**] headache, sinus tenderness, rhinorrhea. 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: cardiac: 1. cad s/p taxus stent to mid rca in [**2101**], 2 cypher stents to mid lad and proximal rca in [**2102**]; 2 taxus stents to mid and distal lad (99% in-stent restenosis of mid lad stent); nstemi in [**7-31**] 2. chf, ef 50-55% on echo in [**7-/2105**] systolic and diastolic heart failure with mild mitral regurgitation and tricuspid regurgitation. 3. pvd s/p bilateral fem-[**doctor last name **] in [**2093**] (right), [**2100**] (left) 4. hypertension 5. atrial fibrillation noted on admission in [**9-1**] 6. dyslipidemia 7. syncope/presyncopal episodes - this was evaluated as an inpaitent in [**9-1**] and as an opt with a koh. no etiology has been found as of yet. one thought was that these episodes are her falling asleep since she has a h/o of osa. she has had no tele changes in the past when she has had these episodes. pulm: 1. severe pulmonary disease 2. asthma 3. severe copd on home o2 3l 4. osa- cpap at home 14 cm of water and 4 liters of oxygen 5. restrictive lung disease other: 1. morbid obesity (bmi 54) 2. type 2 dm on insulin 3. esrd on hd since [**2107-2-28**] - 4x weekly [**year (4 digits) 2286**] tues/thurs/fri/sat 9r 2 lumen tunnelled line 4. crohn's disease - not currently treated, not active dx [**2093**] 5. depression 6. gout 7. hypothyroidism 8. gerd 9. chronic anemia 10. restless leg syndrome 11. back pain/leg pain from degenerative disk disease of lower l spine, trochanteric bursitis, sciatica social history: lives on the [**location (un) 448**] of a 3 family house with [**age over 90 **] year old aunt and multiple cousins in mission [**doctor last name **]. walks with walker. quit smoking in [**2102**], smoked 2.5ppd x 40 years (100py history). infrequent etoh use (1drink/6 months), [**year (4 digits) **] other drug use. retired from electronics plant. family history: per discharge summary: sister: cad s/p cath with 4 stents mi, dm, brother: cad s/p cabg x 4, mi, dm, ther: died at age 79 of an mi, multiple prior, dm, father: [**name (ni) 96395**] mi at 60. she also has several family members with pvd. physical exam: on admission: vs: temp:97 bp: 109/45 hr:99 rr:12 o2sat 100% on ra gen: pleasant, comfortable, nad heent: perrl, eomi, anicteric, mmm, op without lesions, no supraclavicular or cervical lymphadenopathy, jvp not visualized cv: tachycardic, irregular, s1 and s2 wnl, no m/r/g resp: end expiratory wheezes throughout, otherwise cta breasts: large, nodules underlying errythematous patches, ttp abd: obese, nd, +b/s, soft, nt, no masses or hepatosplenomegaly. surgical scar on right side. ext: 1+ edema bilaterally. incision on r leg with stiches in place, mild surrounding errythema, ttp around lesion and in le bilaterally, [**name prefix (prefixes) **] [**last name (prefixes) **] throughout to light touch. skin: as above neuro: aaox3. cn ii-xii intact. moves all extremities freely on discharge: vs: 98.9, 96.8, 98-122/48-71, 84-110, 18-22, 93-99% 3l gen: aox3. somnolant but arousable. cv: irregularly irregular, no m/r/g breasts: on left breast: tender indurated nodules underlying errythematous patches; on right breast: covered with dressing. abd: obese, nd, +b/s, soft, nt, no masses or hepatosplenomegaly. surgical scar on right side. ext: no edema/cyanosis. large black eschar overlying an erythematous base over right thigh; new indurated erythema c/w early lesion on left thigh skin: as above neuro: aox3. cn ii-xii intact. moves all extremities freely pertinent results: admission labs: cbc with diff: [**2108-7-31**] 04:25pm blood wbc-11.4* rbc-2.26*# hgb-6.6*# hct-20.2*# mcv-89 mch-29.3 mchc-32.8 rdw-18.0* plt ct-495* neuts-91.7* lymphs-5.5* monos-2.5 eos-0.2 baso-0.2 chem: [**2108-7-31**] 04:25pm blood glucose-172* urean-44* creat-3.2*# na-135 k-3.6 cl-94* hco3-25 angap-20 calcium-8.9 phos-2.7# mg-1.7 coag: [**2108-7-31**] 12:48pm blood pt-150* inr(pt)->19.2 . discharge labs: cbc: [**2108-8-9**] 07:47am blood wbc-10.7 rbc-3.19* hgb-9.3* hct-28.5* mcv-89 mch-29.1 mchc-32.6 rdw-16.9* plt ct-475* chem: [**2108-8-9**] 07:47am blood glucose-91 urean-35* creat-6.4* na-137 k-5.4* cl-87* hco3-24 angap-31* calcium-9.6 phos-4.7* mg-2.3 coag: [**2108-8-9**] 05:15am blood pt-15.2* ptt-36.8* inr(pt)-1.3* . other: [**2108-8-4**] 06:28am blood pth-397* [**2108-8-5**] 10:40am blood [**doctor first name **]-negative [**2108-8-7**] 01:20pm blood at-115 protcfn-129* protsfn-34* protsag-pnd . micro: blood cx [**7-31**], [**8-1**]: pending . studies: cxr [**2108-7-31**]: findings: hilar prominence and interstitial opacities likely reflect a degree of volume overload in the setting of renal dysfunction. double-lumen left-sided central venous catheter is seen with tips at the cavoatrial junction and well within the right atrium. cardiac size is top normal with normal cardiomediastinal silhouette. unchanged right lung granuloma again seen. impression: mild volume overload . egd [**2108-8-2**]: procedure: the procedure, indications, preparation and potential complications were explained to the patient, who indicated her understanding and signed the corresponding consent forms. a physical exam was performed. a physical exam was performed prior to administering anesthesia. supplemental oxygen was used. the patient was placed in the left lateral decubitus position and an endoscope was introduced through the mouth and advanced under direct visualization until the second part of the duodenum was reached. careful visualization of the upper gi tract was performed. the vocal cords were visualized. the z-line was noted at 39 centimeters.the diaphragmatic hiatus was noted at 40 centimeters.the procedure was not difficult. the patient tolerated the procedure well. there were no complications. findings: esophagus: normal esophagus. stomach: normal stomach. duodenum: normal duodenum. . bone scan ([**2108-8-6**]) impression: 1. possible calciphylaxis vs. poor radionuclide washout in the bilateral distal lower extremities. 2. no evidence of calciphylaxis in the breasts. 3. moderate increased uptake in the lesser trochanter of the left femur of uncertain etiology. 4. stable heterogenous uptake in the thoracolumbar spine also consistent with degenerative changes. . microbiology: blood cultures x2: negative brief hospital course: history: 66 yo woman with hx esrd on hd, afib, presenting with weakness, hypotension and melena concerning for gib. inr at admission found to be >19. pt was admitted to the icu s/p 6u transfusion. bleeding resolved with iv ppi. ugi endoscopy normal. hct stable for 10days. hospital course c/b with calciphylaxis (lower extremity) on sodium thiosulphate and [**month/day/year **] (breast). pain management has been challenging. she has been on iv dilaudid pca, fentanyl patch and standing tylenol. d/ced to rehab on lovenox for anticoagulation, sodium thiosulfate for calciphlaxis, po dilaudid, fentanyl patch and acetaminophen for pain. #. calciphylaxis and [**month/day/year 197**] necrosis: breast lesions biopy c/w [**month/day/year **] necrosis. lower extremity lesions c/w with calciphylaxis based on previus biopsy and bone scan. [**month/day/year 197**] stopped upon admission. calciphylaxis managed on sodium thiosulfate. this may need to be continued for another 6 weeks or more. *please order this medication ahead of time as there is a national shortage( #. chronic pain: pain management had been challenging throughout hospital course. pt continues to have pain despite 0.25-0.36mg dilaudid pca q6mins, with 12.5-100mcg/hr fentanyl patch, and standing 1000mg tylenol q8hr/prn. pain service and palliative care both involved in her care. we will continue her on gabapentin, tylenol 1000mg q8hr/prn, fentanyl patch 25mcg/hr q3days, and po dilaudid 2-4mg q3hrs upon discharge to rehab. she had been monitor for mental status and respiratory depression closely with medication adjustment. please hold dilaudid if repiratory rate <10 or changes in mentation, or somnolance. . #. afib, coagulopathy: held [**month/day/year **] on admission given gib and supratherapeutic inr, which was reversed. [**month/day/year 197**] was not restarted given [**month/day/year **] necrosis on the breasts. additionally, she reportedly had an adverse reaction to plavix in the past. after much discussion with patient, family, pharmacy and renal, we decided to start her on lovenox. the pharmacokinetics of this medication are unclear in [**month/day/year 2286**] (and obesity). accordingly, she will be dosed 80mg q48hr with trough anti10a monitoring prior to each dose. goal anti10a level between 0.2-0.4. if there are problems running this test, please send test to [**hospital1 18**]. #. acute blood loss anemia due to gi bleeding: pt hct drop of 15 points below most recent baseline. ngl in ed was negative. however, pt had reported melena, concerning for upper source. elevated inr likely a contributing factor as supratherapeutic to 19 on admission. her inr was reversed with ffp and vitamin k. she was transfused 2 units of units prbc's in the ed and an additional 4 units while in the icu. she was also started on iv ppi. gi was consulted, and egd showed no active bleeding, presumed due to ppi therapy. she was started on omeprazole 20mg [**hospital1 **] and. her hct stabilized without any repeat bleeding throughout the rest of her course. #esrd hemodialysis was continued with consultation by dr. [**first name (stitle) 805**], her nephrologist. medications were renally dosed. #constipation she was markedly constipated during her admission, finally having multiple bm's with large doses of peg as well as colace, senna. this was due to the high-dose opiates she was receiving. transfer of care 1. continue sodium thiosulfate 3x a week 25mg iv over 30mins with zofran after hd for treatment of calciphylaxis. 2. continue wound care the skin lesions to prevent superinfection. pt is at high risk for bacteremia and sepsis. 3. avoid caustic [**doctor last name 360**] and aggressive debridement of skin lesions given risk of bleeding from underlying arterial source. 4. continue to follow pain and titrate pain medication. 5. close monitoring for mental status changes and respiratory depression closely with pain medication adjustment. 6. continue to monitor for rebleeding from gi tract while on lovenox. 7. continue po omeprazole and transition to daily upon discharge from rehab or at next pcp [**name initial (pre) 648**]. 8. please hold dilaudid if repiratory rate <10 or changes in mentation, and somnolance. medications on admission: hydromorphone (dilaudid) 4 mg po/ng q6h:prn pain ipratropium bromide neb 1 neb ih q6h albuterol 0.083% neb soln 1 neb ih q6h allopurinol 100 mg po/ng daily insulin sc (per insulin flowsheet) levothyroxine sodium 175 mcg po/ng daily acetaminophen 1000 mg po/ng q8h metoprolol tartrate 12.5 mg po/ng [**hospital1 **] calcitriol 0.25 mcg po daily neomycin-polymyxin-bacitracin 1 appl tp doxercalciferol 7 mcg iv once duration: 1 doses order date: [**8-3**] nephrocaps 1 cap po daily omeprazole 20 mg po bid paroxetine 40 mg po/ng daily fluticasone propionate nasal 2 spry nu polyethylene glycol 17 g po/ng daily:prn gabapentin 300 mg po/ng qam gabapentin 600 mg po/ng hs simvastatin 40 mg po/ng daily sodium chloride nasal [**1-29**] spry nu tid:prn dryness tramadol (ultram) 50 mg po q4h:prn pain sevelamer carbonate 800 mg po tid w/meals order date: [**8-3**] @ 0013 discharge medications: 1. [**doctor first name **] bra one [**doctor first name **] bra. [**hospital **] medical products 1-[**numeric identifier 96397**], the bra is latex free ,xx large order # h84107051. 2. allopurinol 100 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. calcitriol 0.25 mcg capsule sig: one (1) capsule po daily (daily). 5. gabapentin 300 mg capsule sig: one (1) capsule po qam (once a day (in the morning)). 6. levothyroxine 175 mcg tablet sig: one (1) tablet po daily (daily). 7. fluticasone 50 mcg/actuation spray, suspension sig: [**1-29**] spray nasal once a day as needed. 8. sevelamer carbonate 800 mg tablet sig: one (1) tablet po tid w/meals (3 times a day with meals). 9. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 10. paroxetine hcl 20 mg tablet sig: two (2) tablet po daily (daily). 11. acetaminophen 500 mg tablet sig: two (2) tablet po q8h (every 8 hours). 12. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 13. sodium chloride 0.65 % aerosol, spray sig: [**1-29**] sprays nasal tid (3 times a day) as needed for dryness. 14. gabapentin 300 mg capsule sig: one (1) capsule po hs (at bedtime). 15. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po daily (daily) as needed for constipation. 16. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po tid (3 times a day). 17. senna 8.6 mg tablet sig: 1-2 tablets po bid (2 times a day) as needed for constipation. 18. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 19. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours): up or down titrate as needed based on total dose of opiates. 20. ondansetron 4 mg iv q8h:prn nausea 21. enoxaparin 80 mg/0.8 ml syringe sig: one (1) injection subcutaneous q48: check anti-factor 10a levels prior to dose. send to [**hospital1 18**] if your lab does not run this value. 22. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 23. lantus 100 unit/ml solution sig: eighteen (18) units subcutaneous at bedtime: . 24. humalog 100 unit/ml solution sig: sliding scale subcutaneous breakfast, lunch, dinner, bedtime as needed for fs level. 25. sodium thiosulfate 25mg sig: one (1) 25mg intravenous every other day: 3x a week at end of hd. 26. please avoid chemical debridement of skin lesions. [**month (only) 116**] cause severe bleeding. avoid tight dressing as it causes signicant pain. sig: [**1-29**] once a day. 27. please titrate pain medicaiton dosage per patient need. monitor for mental status changes with frequent ms checks. monitor for respiratory rate and oxygenation. sig: three (3) once a day. 28. dilaudid 2 mg tablet sig: 1-2 tablets po q3 hours as needed for pain: patient may decline if pain controlled this medicine is scheduled so as to avoid pain crisis. hold if sedated or if patient declines. start with 2mg dose. please titrate dose and frequency to effect . 29. fexofenadine 60 mg tablet sig: one (1) tablet po bid (2 times a day). 30. sarna anti-itch 0.5-0.5 % lotion sig: one (1) application topical four times a day as needed for itching. discharge disposition: extended care facility: [**hospital6 459**] for the aged - macu discharge diagnosis: primary diagnosis: 1. upper gi bleed 2. calciphylaxis secondary diagnosis: 1. end-stage renal disease 2. type 2 diabetes mellitus 3. obstructive sleep apnea on cpap 4. atiral fibrillation 5. hypothyroidism 6. gout 7. rhinitis 8. hyperlipidemia 9. depression discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. [**known lastname 1968**], it was a pleasure taking care of you when you were admitted to [**hospital1 18**] for gastrointestinal bleeding. at admission, we found that your inr was elevated at >19 and that your labs indicated that you had significant blood loss. we stopped your warfarin (coudmadin), gave you blood, and treated you with intravenous proton pump inhibitor for a suspected gastric ulcer. an endoscopy was performed to assess the upper portion of your intestinal tract, but did not find any source of bleeding. you did not show any signs of further blood loss during your hospital course, and your labs showed a stable hematocrit for the past 10days. the second issue during your hospital course was your skin lesions on your right breast and thigh. you had a biopsy of the lower extremity lesions from [**month (only) **], which showed calciphylaxis. we also did a bone scan which was consistent with this diagnosis. dermatology team biopsied your right breast lesion and found that it was consistent with [**month (only) **] necrosis. there had been extensive discussion on which anticoagulation regimen we will send you home with. since you are no longer able tolerate [**month (only) **] and have a history of adverse reactions to plavix, we will discharge you on lovenox for your anticoagulation. we treated you with sodium thiosulfate for your calciphylaxis, and you will continue on this as an outpatient. pain management and palliative care were both involved for the management of your pain. we will send you to rehab with a pain management plan below, which may be adjusted and titrated according to your pain. the medication we stopped upon your admission was: 1. warfarin ([**month (only) **]): we stopped this medication due to a elevated inr, as well as your skin lesions that were consistent with warfarin necrosis. upon discharge the new medication you will be continued on are: 1. lovenox 80mg every other day: this is a medication for anticoagulation. you will have your blood draw before getting the next dose to ensure that anti-10a level is within 0.2-0.4. 2. sodium thiosulfate: you will get 25mg of this medication after hemodialysis over a 30mins infusion period. you will receive zofran during this infusion. this medication may cause hypotension, and you blood pressure should be monitored during this infusion. 3. fentanyl patch: you will go to rehab on 25mcg/hr of fentanyl patch that should be changed every 3 days. please stop the patch if you feel lethargic, confused, or if your feel that you are not breathing well. this may be changed at rehab. 4. hydromorphone 2-4mg every 3 hrs: please stop using it if you feel sleepy, woozy, lethargic or confused. you respiration and oxygenation needs to be monitored while on this medication. this may be changed at rehab. this dose may be readjusted at rehab. 5. senna, colace, miralax: these three medications are to help you move your bowel while on the pain medications. 6. sarna lotion and fexofenadine to help control your itching. other medication changes: 1. gapapentin: we decreased this medication for 300mg qday. they may decided to restart you on your outpatient night-time dose. followup instructions: please schedule a follow up with your primary care doctor [**first name (titles) **] [**last name (titles) **]e from rehab department: dermatology when: monday [**2108-8-20**] at 3:00 pm with: [**doctor first name **]-[**first name8 (namepattern2) **] [**last name (namepattern1) 8476**], md, phd [**telephone/fax (1) 1971**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) 551**] campus: east best parking: [**hospital ward name 23**] garage department: radiology when: [**hospital ward name **] [**2108-9-14**] at 9:05 am with: radiology [**telephone/fax (1) 327**] building: [**hospital6 29**] [**location (un) 861**] campus: east best parking: [**hospital ward name 23**] garage department: [**hospital ward name **] surgery when: [**hospital ward name **] [**2108-9-21**] at 10:00 am with: [**year (4 digits) **] lmob (nhb) [**telephone/fax (1) 1237**] building: lm [**hospital ward name **] bldg ([**last name (namepattern1) **]) [**location (un) **] campus: west best parking: [**hospital ward name **] garage completed by:[**2108-8-10**]",1
102,"admission date: [**2154-5-6**] discharge date: [**2154-5-9**] date of birth: [**2082-1-21**] sex: f service: medicine allergies: lisinopril / [**last name (un) **]-angiotensin receptor antagonist attending:[**first name3 (lf) 905**] chief complaint: angioedema major surgical or invasive procedure: nasogastric intubation mechanical ventilation history of present illness: 72 yo with history of esrd, anemia, htn, presented with tongue swelling. the patient was recently started on lisinopril last week by her pcp. [**name10 (nameis) **] patient had reported to her outpatient pcps office within a few days of starting lisinopril and was found to have unilateral facial swelling. the family was concerned, however her pcp instructed the patient to continue to take lisinopril. the day following, the patient's son took her to a dentist. the dentist thought her teeth were not the culprit of the swelling. per her son, she denied any symptoms other than facial swelling. the patient presented to the ed because of difficulty speaking and swallowing. . in the ed, initial vs were 97.2 70 130/55 18 100%. her exam was significant for profoundly swollen tongue obstructing her airway, drooling and having difficulty phonating. anesthesia was consulted for urgent airway. her labs returned with crn of 3.4, k of 5.2. she received an epi pen, 50mg iv benadryl, 120mg iv hydrocortisone, inhaled racemic epi, 20mg iv famotidine. nasaltracheal intubation was performed with cocaine for anesthetic purposes. she was started on propofol for sedation. one piv was placed and a second placed prior to transfer. her vs in the or and pacu have been stable. she is coming to the micu for continued monitoring. past medical history: -hypertension -hyperuricemia/gout -stage iv ckd - baseline 2.8 -anemia ([**1-30**] ckd) -renal osteodystrophy -osteoarthritis -uterine fibroids -s/p excision cyst from r breast -s/p unilateral salpingo-oophorectomy after ectopic pregnancy -s/p tonsillectomy social history: takes care of [**age over 90 **] yo mother and 50 year old daughter with down's syndrome. - tobacco: 1 pack cigarettes every 1 1/2 days - alcohol: daily use - illicits: per omr denies family history: mother alive at 91 (had two mi's; age unknown); father died of lung cancer. physical exam: on admission: general: intubated sedated with nasotracheal intubation in place heent: extremely edematous tongue taking up the whole oropharynx and coming out of the mouth, sclera anicteric, mmm, mild exopthalmous, ogt in place neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema on discharge: avss heent: no edema lungs: ctab pertinent results: admission labs: [**2154-5-6**] 09:50am blood wbc-6.5 rbc-3.88* hgb-12.0 hct-36.0 mcv-93 mch-31.0 mchc-33.5 rdw-17.6* plt ct-244 [**2154-5-6**] 09:50am blood pt-11.8 ptt-27.0 inr(pt)-1.0 [**2154-5-6**] 09:50am blood glucose-112* urean-41* creat-3.7* na-139 k-5.2* cl-104 hco3-21* angap-19 [**2154-5-6**] 04:43pm blood calcium-8.8 phos-6.2* mg-2.7* [**2154-5-6**] 05:53pm blood type-[**last name (un) **] po2-121* pco2-37 ph-7.30* caltco2-19* base xs--7 . [**2154-5-6**] cxr: 1. probable left lower lobe pneumonia, new since [**2152-3-22**]. 2. satisfactory placement of medical devices. 3. a vertical linear lucency traversing the right lung is most likely due to a skin fold and could be clarified by a followup radiograph, and ensuring the absence of skin folds adjacent to the detector. . discharge labs: [**2154-5-9**] 06:20am blood wbc-9.9 rbc-3.04* hgb-9.2* hct-27.7* mcv-91 mch-30.4 mchc-33.4 rdw-17.7* plt ct-205 [**2154-5-9**] 12:45pm blood hct-32.0* [**2154-5-6**] 04:43pm blood neuts-85.6* lymphs-11.4* monos-1.2* eos-1.3 baso-0.6 [**2154-5-9**] 06:20am blood plt ct-205 [**2154-5-9**] 06:20am blood glucose-104* urean-54* creat-3.0* na-145 k-2.7* cl-109* hco3-20* angap-19 [**2154-5-9**] 12:45pm blood na-141 k-3.5 cl-106 [**2154-5-9**] 06:20am blood calcium-7.9* phos-4.4# mg-2.3 [**2154-5-6**] 04:43pm blood c4-37 brief hospital course: 72f esrd, anemia, htn, admitted for angioedema secondary to lisinopril that required [**last name (un) **]-tracheal intubation that improved with steroids. active issues # angioedema: likely secondary to lisinopril given time course as patient started medication the week prior to presentation. patient required [**last name (un) **]-tracheal intubation in operating room. patient was intubated from [**2154-5-6**] - [**2154-5-8**]. she sucessfully passed spontaneous breathing trial and was extubated. allergy was consulted. patient was initially treated with iv solumedrol q8h and iv benadryl q8h. patient was also treated with famotidine. a c4 level was checked and was normal. patient's angioedema improved and she was extubated. steroids were changed to prednisone 60 mg daily for 3 days. the benadryl was continued to oral prn dosing. patient was called out from icu to medicine floor. on the floor the pt had no swelling and was discharged with 2 additional days of po prednisonde. . # aspiration pneumonitis: patient likely has aspiration event during episode of angioedema. her sputum culture grew gram positive cocci in pairs, chains and clusters, gram negative diplococci, and gram negative rods. patient also developed leukocytosis while in icu. this may have been secondary to steroids, but we were also concerned for infection. started vancomycin and zosyn in micu to cover for vap. repeat cxr showed complete resolution of her symptoms and antiobiotics were . # acute on chronic renal failure: likely secondary to ain from lisinopril or volume depletion from decreased po intake from inability to swallow. patient had positive urine eos. she was continued on her home calcitriol and sodium bicarbonate. her creatinine improved to 3.0 on discharge (baseline 2.8) . inactive issues: # anemia: at baseline, continued outpatient darbopoetin. guaiac negative. . # htn: initially patient's nifedipine was held in micu. when sedation was weaned and patient was extubated, blood pressures were more elevated. patient was restarte on home nifedipine. . transitional issues: the pt is the caregiver of her 95 mother. the pt uses a cane when walking outside. the pt was discharged with home pt after inpatient physical therapy deemed that she reuired additional strength training and physical therapy at home following her hospitalization that included intubation. this was set up prior to discharge. joy ferrara (vna) is the contact individual that set up home services. . # code: full (discussed with son) medications on admission: allopurinol 100 mg daily calcitriol 0.5 mcg 1 on odd days, 2 on even days darbepoetin 40mcg/ml once a month folic acid 6 mg daily lisinopril 5 mg daily nifedipine 90 mg qhs ferrous gluconate 324 mg [**hospital1 **] multivitamin daily sodium bicarbonate 650 mg tid discharge medications: 1. prednisone 20 mg tablet sig: three (3) tablet po daily (daily) for 2 days. disp:*6 tablet(s)* refills:*0* 2. calcitriol 0.25 mcg capsule sig: one (1) capsule po every other day (every other day). 3. calcitriol 0.25 mcg capsule sig: four (4) capsule po every other day (every other day). 4. multivitamin tablet sig: one (1) tablet po daily (daily). 5. folic acid 1 mg tablet sig: six (6) tablet po daily (daily). 6. allopurinol 100 mg tablet sig: one (1) tablet po once a day. 7. sodium bicarbonate 650 mg tablet sig: one (1) tablet po tid (3 times a day). 8. nifedipine 90 mg tablet extended release sig: one (1) tablet extended release po daily (daily). 9. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po twice a day. 10. darbepoetin alfa in polysorbat 40 mcg/0.4 ml syringe sig: one (1) injection once a month. 11. eye drops ophthalmic discharge disposition: home with service facility: [**location (un) 86**] vna discharge diagnosis: primary diagnosis - angioedema - aspiriation pneumonitis 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 following an adverse reaction from lisinopril. you were intubated to protect your airway and given steroids to decrease the swelling in your throat. the swelling resolved and you were given oral prednisone. . we have started the following medication: 1) prednisone 60mg daily for two days followup instructions: please call to make an appointment with dr. [**first name4 (namepattern1) **] [**last name (namepattern1) **] [**telephone/fax (1) 3581**] in the next 1-2 weeks. department: west [**hospital 2002**] clinic when: friday [**2154-5-24**] at 10:00 am with: [**first name8 (namepattern2) **] [**last name (namepattern1) **] [**telephone/fax (1) 17762**] building: de [**hospital1 **] building ([**hospital ward name 121**] complex) [**location (un) **] campus: west best parking: [**street address(1) 592**] garage department: west [**hospital 2002**] clinic when: wednesday [**2154-8-21**] at 9:30 am with: [**first name8 (namepattern2) **] [**last name (namepattern1) 2540**], rn [**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: west [**hospital 2002**] clinic when: wednesday [**2154-10-16**] at 11:00 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 [**name6 (md) 251**] [**name8 (md) **] md [**md number(1) 910**]",1
103,"admission date: [**2106-11-25**] discharge date: [**2106-12-5**] date of birth: [**2037-6-2**] sex: f service: medicine allergies: effexor / cefepime attending:[**first name3 (lf) 4358**] chief complaint: neck pain, sob major surgical or invasive procedure: none history of present illness: 69f h/o htn, hypothyroidism, tracheobronchomalacia s/p surgery [**1-/2106**], copd on 4l home o2, osa on vpap, prior admission for pna with and icu stay, who p/w 3d of pain in back of head, unsteady gait, and cough. pt states that her symptoms began 3-4 days ago with pain in the back of her head, more significant on the r side. it starts at the back of the head, near the occiput, and travels up the scalp to the forehead. this pain is intermittent, shooting sharp pain that happens every 5-10 min and has been increasing in frequency. she has tried ibuprofen for the pain but with no relif. she denies any associated dizziness, lightheadedness, or blurry vision. she has also been having a productive cough of thick, yellow sputum, along with increasing oxygen requirement. she notes that she has oxygen at home, but usually only uses it in the car (at 4l) but recently has been having to use it during the day as well. her wife, who is at her bedside, has noticed that the pt has had an unsteady gait for the past few days in which the pt will stumble after walking a few steps and she states she has to catch the pt to prevent her from falling. in ed vs were 98.6 86 122/68 16 95% 4l. labs significant for wbc 18.7 with left shift. cxr demonstrated large lul consolidation, widening of mediastinum [**3-3**] lymphadenopathy. given levaquin 750mg iv x1. vs on transfer t 102.1, hr 88, bp 115/59, rr 22 - 26, spo2 95% on 4lo2 nc. on the floor, t 101.7, bp 124/60. she appeared comfortable and was accompanied by her wife who was at her bedside. her wife noted that she felt she had an upper respiratory tract infection about 4-5 days prior. she was experiencing the shooting pains at the back of her head during the interview, but she stated it didn't prevent her from doing her daily activities. she endorsed an intentional 70lb weight loss in the past 16 mos. review of systems: (+) per hpi (-) denies fever, chills, night sweats. denies sinus tenderness, rhinorrhea or congestion. denied chest pain or tightness, palpitations. denied nausea, vomiting, diarrhea, or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias. past medical history: hypertension hypothyroid restless leg syndrome copd tbm depression elevated cholesterol osteoarthritis gerd obstructive sleep apnea past surgical history: bilateral knee replacements oophorectomy on left tonsillectomy rotator cuff repair social history: lives with wife. [**name (ni) **] works for the census bureau collecting data in hospitals. no current tobacco use, smoked 3ppd, quite 25 years ago. no history of drug use. she is a recovering alcoholic, sober since [**2082**]. the patient's weekly exercise regimen consists of exercising three times per week for 1 hour. family history: father: hypothyroidism, early onset alzheimer's disease, died at 65. mother: died of cva at age 85. physical exam: admission physical exam vs: t 100.1, bp 120/60, p 90, r 32, o2 93 4l ga: aox3, nad, calm and appropriate heent: perrla. mmm. no lad. no jvd. neck supple. cards: rrr s1/s2 heard. s3 auscultated. no murmurs/gallops/rubs. pulm: decreased breath sounds l>r, but no rales/wheezes/rhonchi abd: soft, nt, nd, +bs. extremities: wwp, no edema. radials, dps, pts 2+. skin: dry and intact pertinent results: admission labs [**2106-11-25**] 01:50pm blood wbc-18.7*# rbc-4.16* hgb-12.7 hct-38.5 mcv-93 mch-30.7 mchc-33.1 rdw-12.9 plt ct-256 [**2106-11-25**] 01:50pm blood neuts-92.5* lymphs-3.8* monos-2.8 eos-0.8 baso-0 [**2106-11-25**] 01:50pm blood glucose-115* urean-15 creat-1.0 na-134 k-3.5 cl-93* hco3-26 angap-19 [**2106-11-26**] 05:55am blood alt-28 ast-34 alkphos-106* totbili-0.4 [**2106-11-25**] 01:50pm blood calcium-8.5 phos-2.8 mg-2.3 [**2106-11-26**] 12:06pm blood type-art po2-78* pco2-32* ph-7.50* caltco2-26 base xs-1 microbiology [**2106-11-25**] blood culture x2: [**2106-11-26**] blood culture x2: [**2106-11-25**] legionella urinary antigen (final [**2106-11-26**]): negative for legionella serogroup 1 antigen. [**2106-11-26**] urine culture (final [**2106-11-27**]): mixed bacterial flora ( >= 3 colony types), consistent with skin and/or genital contamination. [**2106-11-26**] mrsa screen: positive [**2106-11-27**] influenza dfa: negative [**2106-11-29**] and [**2106-12-2**] sputum cultures: contaminated by oral flora [**2106-12-2**] urine culture: pending at time of d/c, no growth to date [**2106-12-2**] blood culture: pending at time of d/c, no growth to date imaging [**2106-11-25**] ecg: normal sinus rhythm. left atrial enlargement. incomplete right bundle-branch block. compared to the previous tracing of [**2105-12-17**] ventricular bigeminy no longer exists. [**2106-11-25**] chest (pa & lat): there is widening of the mediastinum, particularly the right lower paratracheal region, compatible with lymphadenopathy, as demonstrated on the recent chest cts from [**2106-10-19**] and [**2106-4-5**]. there is a new consolidative opacity in the left upper lobe compatible with pneumonia. lungs are hyperinflated with lucency and relative attenuation of pulmonary vascular markings in the upper lobes compatible with underlying emphysema. no pleural effusion or pneumothorax is present. there are mild degenerative changes of the thoracic spine. right-sided rib deformities are unchanged. [**2106-11-25**] ct head w/o contrast: there is no evidence of acute hemorrhage, large acute territorial infarction, or large masses. there are bilateral subcortical and periventricular white matter hypodensities in keeping with chronic small vessel ischemic changes. ventricles and sulci are normal in size and configuration. mucosal thickening is seen in all the paranasal sinuses, most severe in the left frontal and right sphenoid sinus, with sparing of the right frontal sinus, which is . mastoid air cells are well pneumatized. [**2106-11-26**] chest (portable ap): lung volumes are lower today than yesterday and there is mild vascular congestion but not florid pulmonary edema. lower lung volumes exaggerate the size of the already large area of consolidation in the left upper lobe, but the overall impression is that it has grown. there is no appreciable left pleural effusion. mediastinal fullness suggests central lymph node enlargement, not surprising in the face of a large area of pneumonia. heart size is top normal. no pneumothorax. patient has had right chest surgery, entailing posterior upper rib fractures, which are not completely fused. [**2106-11-26**] ct chest w/o contrast: there is dense consolidation with air bronchograms centered predominantly within the lingula with extension into the apicoposterior segment of the superior lobe. scattered additional predominantly peripheral interstitial abnormalities were present on the prior examination and likely represent fibrosis. there is severe upper lobe predominant emphysema. a 3-mm left apical pulmonary nodule is unchanged (3:7), as is a 4-mm left lower lobe pulmonary nodule (3:27) dating back to [**2105-11-17**], establishing one-year stability. there is mild bilateral dependent atelectasis. there are coronary artery and aortic calcifications. no pericardial effusion is seen. a left hilar node measures 2.0 cm in short axis, a right paratracheal node 1.5 cm in short axis, and a prevascular node 1.6 cm in short axis, all increased in size from [**2106-10-27**] ct. other smaller reactive nodes are noted throughout the mediastinum. [**2106-11-28**] chest x-ray: impression: compared to the film from two days prior, there has been some interval partial clearing of the dense left-sided infiltrate, which although still present, has slightly more aerated lung within it. right upper rib fractures are again seen secondary to prior surgery. there continues to be mild vascular congestion. [**2106-12-1**] chest x-ray: findings: in comparison with the study of [**11-30**], there is little overall change in the appearance of the heart and lungs. extensive bilateral opacifications are unchanged. no evidence of pleural effusion or vascular congestion [**2106-12-3**] kub: 1. normal gas pattern without evidence of obstruction or ileus. 2. no free air. 3. compression fracture of l5. [**2106-12-3**] cxr: pneumonia in the axillary region of the left lung continues to clear. change in patient positioning is probably responsible for greater prominence to the prevascular mediastinum crossing the upper portion of the right hilus. the heart is normal size. emphysema is severe, and the pulmonary fibrosis is likely at the lung periphery. there are no findings to suggest new pneumonia. discharge labs: [**2106-12-5**] 06:02am blood wbc-15.6* rbc-4.44 hgb-13.6 hct-40.6 mcv-91 mch-30.6 mchc-33.4 rdw-13.2 plt ct-587* [**2106-12-5**] 06:02am blood plt ct-587* [**2106-12-5**] 06:02am blood glucose-89 urean-23* creat-1.0 na-141 k-4.0 cl-104 hco3-28 angap-13 [**2106-12-5**] 06:02am blood calcium-8.8 phos-4.4 mg-2.2 brief hospital course: 69f h/o htn, hypothyroidism, tracheobronchomalacia s/p surgery [**1-/2106**], copd on 4l home o2, osa on vpap, prior admission for pna with and icu stay, who p/w 3d of pain in back of head, unsteady gait, lul pna. # [**name (ni) 96987**] pneumonia - pt's high fever, cough, leukocytosis, chest x-ray all consistent with pneumonia. she was initially treated with levofloxacin 750mg po daily but on the second hospital day, pt triggered for fever to 103.2 and hypoxia. she was transfered to the icu on a non-rebreather mask with oxygen saturation sat 94%. her antibiotics were broadened to include vancomycin and cefepime upon transfer. while in the micu, her cefepime was discontinued due to adverse reaction (rash). she was continued on vancomycin. levaquin and tobramycin were added for double gram-negative coverage. her symptoms and radiographic findings improved significantly with this regimen that she finished on [**12-3**]. # leukocytosis: despite improvement on the above antibiotic regimen for pneumonia, she developed a leukocytosis which peaked at 20 without clear cause. cxr and kub as well as laboratory studies were unrevealing. c diff infection was considered but patient did not stool and no sample was collected. given her overall clinic improvement with a lack of and pain or diarrhea and improving leukocytosis further testing was deferred. surveillance cultures remained no growth to date at the time of discharge. # copd/tracheobronchiomalacia - pt was continued on her home advair, zafirlukast, sprivia, proair, with albuterol nebs q6 standing, q2prn. # neck/head pain - etiology unclear. could be occipital neuralgia given the transient, intermittent, sharp shooting nature of the pain. pain was refractory to tylenol, increased dose of gabapentin, lidocaine patch and soft collar brace. # osa - vpap per home settings. # hypothyroidism - continued levothyroxine at home dose # gerd - continued home omeprazole # dyslipidemia - continued pravastatin # hypertension - continued triamterene-hctz . transitional: - follow up final blood and urine cultures. medications on admission: cabergoline 0.5 mg qod for rls fluticasone proprionate 50mcg: 2 sprays each nostril [**hospital1 **] advair (inhaler) 250/50: 1 puff [**hospital1 **] gabapentin 600mg qam, 900 mg qhs levothyroxine 137 mcg daily omeprazole delayed-release 40mg [**hospital1 **] pravastatin 40 mg qhs sertraline 100 mg twice a day tolterodine 4 mg once a day triamterene-hydrochlorothiazid - 37.5-25 mg once a day zafirlukast 20mg [**hospital1 **] ascorbic acid 500mg once daily calcium/mg/zn 333/133/5mg [**hospital1 **] ferrous sulfate 65 mg [**hospital1 **] centrum silver for women vitamin e 400 iu qd dha (fishoil/omega3oil) 250mg daily ic albuterol 90 mcg inhaler 1-2 puffs iprat-albuterol (via nebulizer) 1 0.5-3.0 mg ampule up to qid discharge medications: 1. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 2. zafirlukast 20 mg tablet sig: one (1) tablet po bid (2 times a day). 3. triamterene-hydrochlorothiazid 37.5-25 mg capsule sig: one (1) cap po daily (daily). 4. gabapentin 300 mg capsule sig: three (3) capsule po qhs (once a day (at bedtime)). 5. gabapentin 300 mg capsule sig: two (2) capsule po qam (once a day (in the morning)). 6. levothyroxine 137 mcg tablet sig: one (1) tablet po daily (daily). 7. sertraline 50 mg tablet sig: one (1) tablet po bid (2 times a day). 8. pravastatin 20 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)). 9. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation [**hospital1 **] (2 times a day). 10. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: two (2) puff inhalation qid (4 times a day) as needed. 11. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 ml solution for nebulization sig: one (1) cap inhalation qid prn as needed for shortness of breath or wheezing. 12. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po bid (2 times a day). 13. cabergoline 0.5 mg tablet sig: one (1) tablet po qod: rls. 14. fluticasone 50 mcg/actuation spray, suspension sig: one (1) puff nasal once a day: in each nostril. 15. tolterodine 4 mg capsule, ext release 24 hr sig: one (1) capsule, ext release 24 hr po once a day. discharge disposition: extended care facility: [**hospital 1514**] health care center - [**location (un) 1514**] discharge diagnosis: bacterial lobar pneumonia secondary dx: osa pulmonary hypertension pulmonary fibrosis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mrs. [**known lastname 96986**], it was a pleasure taking care of you. you were admitted to the hospital for pneumonia. because you have underlying lung disease, you became very ill and temporarily required icu level care. you were treated with iv antibiotics and your condition improved. you are currently stable and we now believe that you are safe to leave the hospital for rehab. . please continue taking all of your home medications. . followup instructions: department: medical specialties when: monday [**2107-1-3**] at 1 pm with: [**first name8 (namepattern2) **] [**name8 (md) **], m.d. [**telephone/fax (1) 612**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) **] campus: east best parking: [**hospital ward name 23**] garage department: rheumatology when: thursday [**2107-2-17**] at 12:30 pm with: [**first name5 (namepattern1) **] [**last name (namepattern1) **], md [**telephone/fax (1) 2226**] building: lm [**hospital ward name **] bldg ([**last name (namepattern1) **]) [**location (un) 861**] campus: west best parking: [**hospital ward name **] garage",1
104,"admission date: [**2171-7-17**] discharge date: [**2171-7-25**] date of birth: [**2109-6-17**] sex: f service: general surgery/blue chief complaint: elective repair of a retroperitoneal sarcoma. history of present illness: this is a 62-year-old female who has been complaining of a right-sided abdominal pain/flank pain for the past six months. the patient has been gradually increasing in severity. this has been associated with a loss of appetite and a 20-pound weight loss over this time. in addition, there are also complaints of a right lower extremity numbness and tingling. cat scan reveals a large right retroperitoneal tumor involving the inferior vena cava associated with a right hydronephrosis. a cat scan-guided biopsy of this mass revealed a spindle cell tumor. past medical history: 1. gerd. 2. hiatal hernia. 3. kidney stones. 4. status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. 5. status post open cholecystectomy. drug allergies: no known drug allergies. meds at home: include tylenol #3. social history: she has no toxic habits. physical exam on presentation: she is afebrile, pulse 73, blood pressure 159/82. oxygen saturation 98% on room air. she is a healthy appearing female in no apparent distress. cardiovascular - regular rate and rhythm. lungs clear to auscultation bilaterally. abdomen - soft, nontender, nondistended abdomen, positive bowel sounds. she has a firm, nontender mass in the right abdomen. there is no associated lymphadenopathy. there is a right upper quadrant scar from her old cholecystectomy. hospital course: so, the patient presented on [**2171-7-17**]. after consent was obtained, the patient was brought to the operating room for an elective resection of the retroperitoneal spindle cell tumor by dr. [**last name (stitle) **] who was assisted in this case by dr. [**last name (stitle) 3407**] and dr. [**first name (stitle) **]. during this procedure, the patient had a swan-ganz catheter placed to monitor her hemodynamics intraoperatively and also postoperatively. please refer to dr. [**last name (stitle) **], dr. [**last name (stitle) 3407**] and dr.[**name (ni) 670**] operative notes for a more detailed description of the procedure. in short, there was 1) a radical resection of the retroperitoneal sarcoma, 2) a radical resection of the right kidney and ureter, 3) pelvic and retroperitoneal lymph node resection, 4) ligation and resection of the infrarenal inferior vena cava, and 5) intraoperative radiation therapy administered to the retroperitoneal tumor bed. dr. [**last name (stitle) **] performed the resection of the sarcoma, the lymph node resection, and she opened and closed. dr. [**first name (stitle) **] performed the resection of the kidney and the ureter, and dr. [**last name (stitle) 3407**] performed the ligation and resection of the inferior vena cava. finally, [**initials (namepattern4) **] [**last name (namepattern4) 1661**]-[**location (un) 1662**] drain was placed in the tumor bed. postoperatively, the patient was transferred to the surgical intensive care unit in good condition, but intubated. in the icu, the patient was gradually weaned from her ventilator. in addition, she was resuscitated with intravenous fluids because of her hypovolemic state, and she was transfused with red blood cells multiple times. her pain, at first, was controlled with propofol which kept her sedated, and then subsequently after she was extubated, she was maintained on a morphine pca device. in addition, once she became lucid, she was slowly advanced on a po diet, and by the time she was transferred to the floor on [**7-21**], postop day #4, she was tolerating a clear liquid diet without nausea, vomiting or abdominal pain. incidentally, the patient had an adverse reaction to some of the tape that was used upon her belly and developed several skin blisters secondary to this tape reaction. once on the floor, the patient was given po pain medications. she was quickly advanced to a regular diet which she tolerated without nausea, vomiting or abdominal pain. her central venous line was discontinued, as was her foley catheter. we continued to diurese her with intravenous lasix doses and then subsequently po lasix doses. she was evaluated by physical therapy who concluded that she could safely go home with continued rehabilitation treatment. on [**7-25**], the day of discharge, the patient was afebrile, pulse 86, blood pressure 122/70, oxygen saturation 93% on room air. she weighed 83.1 kg which was approximately 10 kg above her admit weight. she was tolerating a po diet and urinating very well. her jp was still putting out serosanguineous fluid. on general exam, she was alert and oriented x 3 in no apparent distress. cardiovascular - regular rate and rhythm. lungs - clear to auscultation bilaterally. abdomen soft, nontender, nondistended with minimal erythema from the blisters secondary to her tape reaction. her jp was pulled with a stitch in place. her lower extremities did have 1+ pitting edema up to her midthighs. in addition, she had 1+ dorsalis pedis pulses. she was discharged home in good condition on the 21. discharge diagnoses: 1. gastroesophageal reflux. 2. hiatal hernia. 3. status post total abdominal hysterectomy, bilateral salpingo-oophorectomy. 4. status post open cholecystectomy. 5. status post radical resection of retroperitoneal sarcoma. 6. status post radical resection of right kidney and right ureter. 7. status post infrarenal inferior vena cava ligation and resection. 8. status post swan-ganz catheter placement for hemodynamic monitoring. 9. hypovolemia requiring fluid resuscitation. 10.chronic blood loss anemia requiring red blood cell transfusion. 11.exchange of a central venous catheter. discharge medications: 1. silvadene cream apply topically tid. 2. vicodin tablets 1 tablet po q 4-6 h prn pain. 3. colace 100 mg [**hospital1 **] prn constipation. 4. lasix 20 mg po qd for 7 days. 5. potassium chloride 20 meq 1 po bid for 1 week. discharge instructions: 1. diet as tolerated. 2. she is to receive rehab services at home. 3. she is to contact dr.[**name (ni) 22019**] office to arrange a follow-up appointment in 2 weeks. [**name6 (md) 843**] [**name8 (md) 844**], m.d. [**md number(1) 845**] dictated by:[**last name (namepattern1) 21933**] medquist36 d: [**2171-8-8**] 12:33 t: [**2171-8-8**] 12:27 job#: [**job number 95869**]",1
105,"admission date: [**2188-8-24**] discharge date: [**2188-8-26**] date of birth: [**2160-3-2**] sex: f service: medicine allergies: no drug allergy information on file attending:[**first name3 (lf) 603**] chief complaint: facial swelling, sore throat major surgical or invasive procedure: n/a history of present illness: ms. [**known lastname 1661**] is a 28 yo f with a history of asthma and atypical chest pain who presented to the ed [**8-23**] with the chief complaint of facial swelling and sore throat. she was in her usual state of health until last week when she went to her pcp for ongoing [**name9 (pre) 11756**] (several months) and new rle swelling and parasthesias/weakness. she states that she was given a medication and had an x ray but does not know the results or the name of the medication, which she took only one time. she did not have any other symtpoms until 2 days pta when she developed tongue burning and swelling after eating a slice of pizza. she also developed diarrhea (x 5) and nausea and emesis x 2. of note, her father whom she saw three days earlier also had similar symptoms. she recently went to ny, but denies nay exotic or new foods. . the next morning she developed a sore throat and presented to [**location (un) 2274**] urgent care where her temperature was reportedly 103. she also noticed that the left side of her face was numb and swollen as well as the bottom of the right side of her face. she was sent from the clinic to the ed where ems reported wheezing at the apex, but no stridor. . in the ed, initial vs were: t:97.7 hr:88 bp:114/82 rr:20 o2sat:98. patient was given benadryl 25 mg x 2, famotidine 20 mg iv, decadron 10 mg iv, afrin, magic mouthwash, and clindamycin as well as toradol 30 mg iv x 2, and morphine for pain. overnight her facial swelling improved but sore throat continued. ct scan with contrast showed no parotid abnormalities, no submandibular abnormalities or tissue inflammation. ent was called to evaluate for sore throat. pt reports no change in voice, some drooling overnight but not during the day. throat pain with head turning but no torticollis or trismus. the patient remained afebrile in the ed for 24 hrs. . on the floor, pt c/o chest pain and ha. ekg showed nsr, 81 bpm, nml pr and qrs interval, no st or t wave abnormalities, good r wave progression. past medical history: past medical history: asthma - uses inhaler 2 x week, not on steroids anemia depression/anxiety - not on any medications presumed pericarditis with a flutter vs musculoskeletal pain [**2187**], treated with nsaids s/p ankle surgery s/p appendectomy social history: she is single with two children, works as a patient service coordinator at [**hospital6 **] center. she does not smoke cigarettes. she does not drink alcohol or use recreational drugs. she does exercise approximately an hour per week by walking. she does not follow particular diet. family history: nc physical exam: vitals: t 98.1, bp 124/83, hr 83, 18 and 97%ra gen: resting comfortably, sitting up in bed, nad heent: perrla, eomi, sclera non-injected, mmm, oropharynx clear and without erythema neck: no lad or neck swelling cv: rrr, nl s1/s2, no m/r/g resp: ctab abd: +bs, soft, mildly tender in rlq, non-distended extrem: no c/c/e, 2+ dp and radial pulses neuro: cn ii-xii intact, nonfocal pertinent results: blood . [**2188-8-23**] 07:15pm blood wbc-5.2# rbc-3.83* hgb-11.4* hct-32.6* mcv-85 mch-29.7 mchc-34.9 rdw-13.5 plt ct-363 [**2188-8-23**] 07:15pm blood neuts-77.3* lymphs-18.3 monos-2.2 eos-1.5 baso-0.6 . [**2188-8-23**] 07:15pm blood glucose-99 urean-9 creat-0.8 na-140 k-3.9 cl-109* hco3-22 angap-13 . [**2188-8-24**] 05:00pm blood ck(cpk)-176 [**2188-8-24**] 05:00pm blood ctropnt-<0.01 . [**2188-8-24**] 05:00pm blood c3-123 [**2188-8-24**] 05:00pm blood c4-41* . [**2188-8-23**] 07:15pm urine color-straw appear-clear sp [**last name (un) **]-1.002 [**2188-8-23**] 07:15pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg . micro . mrsa screen (final [**2188-8-27**]): no mrsa isolated. . imaging . ct neck with contrast([**2188-8-24**]) impression: normal appearance of the neck. no imaging evidence of parotitis. . ekg . ([**2188-8-24**]): sinus rhythm. non-specific st-t wave abnormalities. compared to the previous tracing of [**2187-6-27**] no change. ([**2188-8-26**]): probable sinus rhythm. low amplitude p waves. st-t wave abnormalities. since the previous tracing of [**2188-8-24**] there is probably no significant change. brief hospital course: # throat pain/swelling: patient was initially admitted to the icu for an unclear cause of likely allergic reaction versus angioedema. she did not report any new medication a few days prior to the episode or new foods. c1 esterase deficiency was also in the differenital, which could affect the gut and cause gi symptoms. she was by ent and there was no indication for intubation. her o2 saturations were stable and she did not exhibit any stridor or subjective dyspnea. she was transferred to a general medical floor within hours and her diet was advanced as tolerated. she remained stable and her sore throat was treated with lozenges and ""magic mouthwash"" (lidocaine/diphenhydramine/maalox combination). she was watched overnight and discharged on a rapid steroid taper and instructed to follow-up with an allergy specialist to determine a possible cause of her adverse reaction. given her history of asthma and a high incidence of concurrent atopy, it was highly recommended to her to procure an epipen in cases of extreme shortness of breath and to avoid taking nsaids or aspirin, as these are common causes of allergies. . # diarrhea: she was complaining of diarrhea prior to admission that seemed to resolve. this may have been a viral gastroenteritis, as her father was also sick with similar symptoms. . # chest pain: her chest pain was atypical and nonexertional. she does not have any cardiac risk factors and no ekg changes. the h2 blockers and magic mouthwash seemed to improve her symptoms, indicating a likely gi cause of her chest pain. medications on admission: motrin 600 mg p.o. b.i.d. advair (rx but not taking) discharge medications: 1. menthol-cetylpyridinium 3 mg lozenge sig: one (1) lozenge mucous membrane prn (as needed) as needed for throat pain. disp:*30 lozenge(s)* refills:*0* 2. prednisone 10 mg tablet sig: see following instructions po once a day for 3 days: take 3 tablets on day #1 after discharge, then take 2 tablets the following day (day#2), and 1 tablet on the day after that (day #3). disp:*6 tablets* refills:*0* 3. maalox 200-200-20 mg/5 ml suspension sig: five (5) ml po qid (4 times a day) as needed for indigestion. disp:*40 ml(s)* refills:*0* 4. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation every six (6) hours as needed for shortness of breath or wheezing. discharge disposition: home discharge diagnosis: primary diagnosis: allergic reaction of unknown etiology discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure treating you at [**hospital1 1170**]. you were admitted to the hospital with increased facial swelling and numbness, fevers, and a sore throat. we were initially concerned that you were having an allergic reaction that may cause you to have difficulty breathing, so you were brought to the intensive care unit. when it was felt your breathing was stable and your facial swelling decreased, you were transferred to a regular medical floor for further observation. while we could not figure out the cause of your adverse reaction, we would advise you not to take aspirin or nsaids such as motrin or ibuprofen, as there are common causes of allergic reactions. as we discussed, many patients with a history of asthma can also have allergies that are unknown to them. we recommend following up with your primary care physician at [**hospital6 **] and an allergy specialist in the next few weeks. see this information below. we would like you to take 2 medications when you leave the hospital: prednisone 30mg (3 tablets) by mouth daily for 1 day (day #1) prednisone 20mg (3 tablets) by mouth daily for 1 day (day #2) prednisone 10mg (3 tablets) by mouth daily for 1 day (day #3) maalox 5ml by mouth 4 times a day as needed for indigestion menthol-cetylpyridinium (cepacol) 3 mg lozenge by mouth as needed for throat pain. please continue to take all other medications prescribed by your physicians as directed, except for aspirin, motrin, or ibuprofen (as listed above). if you have a recurrence of facial swelling, experience itchiness, or feel like you are having increasing difficulty with breathing, you should report to the emergency room immediately. in coordination with your primary care physician, [**name10 (nameis) **] also recommend that you carry around an epipen with you, just in case you have a severe allergic reaction in the future. followup instructions: as mentioned above, we recommend you follow up with both your primary care physician and an allergy specialist. we have set up these appointments for you and the information is listed below: appointment #1 primary care doctor, dr. [**last name (stitle) **] [**name (stitle) 766**] [**9-1**] at 4:40 pm if you need to reschedule this appointment please call [**telephone/fax (1) 2261**] appointment #2 allergist, [**location (un) 442**] [**location (un) **], dr. [**last name (stitle) 82506**] wednesday [**9-3**], 8:40 am if you need to reschedule this appointment please call [**telephone/fax (1) 82507**]",1
106,"admission date: [**2134-5-6**] discharge date: [**2134-5-8**] date of birth: [**2062-2-16**] sex: m service: medicine allergies: aspirin / ibuprofen attending:[**first name3 (lf) 458**] chief complaint: asa desensitization major surgical or invasive procedure: cardiac catherization with placement of drug-eluting stent to right coronary artery aspirin desensitization history of present illness: 72 y/o m with hypertension and asthma referred for aspirin desensitization prior to cardiac catheterization [**5-7**]. he describes taking aspirin many years ago in the hospital and having throat swelling and shortness of breath. he gets similar symptoms with ibuprofen. he does not get hives or itching. he has had recent intermittent episodes of substernal/midepigastric discomfort described as gas pain, lasting ~3 hrs., associated with belching, and relieved by tums. no associated dizziness, lightheadedness, diaphoresis, palpitations, shortness of breath, or vomiting. no component of exertion or position. no orthopnea, pnd, or edema. symptoms evaluated with ett-mibi [**5-5**] during which he exercised for 4:37 reaching 7 mets and 91% of max predicted hr. at peak exercise he had chest discomfort with 2-[**street address(2) 82585**] depressions inferiolaterally and ventricular ectopic activity with couplets - chest pain resolved with ntg. initial images showed inferior defect. also had asymptomatic 4-beat run of vt in immediate post-recovery period. tte [**5-6**] showed normal lv size and systolic function (lvef 65%), 2+ mr, 1+ tr, and trace ar. . on review of systems, he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. all of the other review of systems were negative except as noted above. . cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. past medical history: hypertension prostate cancer s/p prostatectomy [**2125**] nasal polyps asthma s/p removal nasal polyps s/p tonsillectomy cri - cr 1.5 on [**2134-5-5**] social history: one glass of wine daily. quit smoking in [**2085**]. o tobacco or ivdu. lives with wife in [**name2 (ni) **]. retired truck driver family history: no h/o premature cad or scd. mother died of breast ca at 52. father died of lung ca at 72. physical exam: v/s: t 98.4 hr 95 bp 111/69 gen: well-appearing gentleman in nad heent: nc/at. sclera anicteric. conjunctiva pink, no xanthalesma. neck: supple with jvp of 6 cm @ hob 45 deg. no carotid bruit. cv: pmi located in 5th intercostal space, midclavicular line. rr, normal s1, s2. ii/vi holosystolic murmur at apex, no thrills, lifts. no s3 or s4. chest: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abd: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. ext: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ dp 2+ pt 2+ left: carotid 2+ dp 2+ pt 2+ pertinent results: admission labs: [**2134-5-6**] 02:19pm blood wbc-8.6 rbc-4.72 hgb-14.5 hct-41.9 mcv-89 mch-30.6 mchc-34.5 rdw-12.9 plt ct-307 [**2134-5-6**] 02:19pm blood neuts-65.4 lymphs-24.8 monos-7.1 eos-2.2 baso-0.6 [**2134-5-6**] 02:19pm blood pt-13.6* ptt-24.6 inr(pt)-1.2* [**2134-5-6**] 02:19pm blood glucose-122* urean-27* creat-1.3* na-138 k-3.9 cl-104 hco3-24 angap-14 [**2134-5-6**] 02:19pm blood calcium-9.5 phos-2.8 mg-1.9 [**2134-5-7**] 05:25am blood triglyc-119 hdl-45 chol/hd-3.6 ldlcalc-91 . . chest x-ray: normal heart, lungs, hila, mediastinum and pleural surfaces aside from a descending thoracic aorta, which is at least tortuous and may be mildly dilated. conventional radiographs recommended for initial assessment cardiac cath:(prelim report) initial angiography showed 80% mid rac and 50% distal rca at crux. we planned to treat the mid rca lesion with ptca and stenting. bivaliruding provided adequate support. the patient also received asa and plavix prior to the procedure. a 6 french jr4 guide provided adequate suport. choice floppy wire crossed the lesion without dufficulty and was positioned in the distal rpda. a 3.0x12 mm quantum maverick rx predilated the lesion at 18 atm. we then deployed a 3.0x15 mm endeavor stent rx at 16 atm. final angiography showed 0% residual stenosis with timi 3 flow and no dissection or distal emboli. we then successfully deployed a 6 french angioseal closure device into the rcfa. the patient left the carth lab free from angina and in stable condition. comments: 1. selective coronary angiography of this right-dominant system demonstrated two-vessel coronary artery disease. the lmca had no significant stenoses. the lad had sequential 50% stenoses in the mid- and distal-vessel. the lcx had mild insignificant plaque. the rca had an 80% mid-vessel stenosis and a 50% stenosis at the pda/plv bifurcation. 2. resting hemodynamics demonstrated high-normal biventricular filling pressures and mild pulmonary arterial hypertension as above. 3. successful ptca and stening of the mid rac with 3.0x15 mm endeavor des. final angiography showed 0% residual stenosis with timi 3 flow and no dssection or distal emboli. 4. successful deployment of a 6 french angioseal closure device to the rcfa. final diagnosis: 1. two vessel coronary artery disease. 2. successful ptca and stenting of the mid rca with endeavor des. 3. successful deployment of 6 french angoseal device to the rcfa. . discharge labs: [**2134-5-8**] 02:56am blood wbc-10.0 rbc-4.01* hgb-12.4* hct-36.4* mcv-91 mch-31.1 mchc-34.2 rdw-13.0 plt ct-288 [**2134-5-8**] 02:56am blood glucose-87 urean-20 creat-1.3* na-140 k-4.4 cl-106 hco3-27 angap-11 [**2134-5-8**] 02:56am blood calcium-8.6 phos-3.3 mg-2.1 [**2134-5-7**] 05:25am blood triglyc-119 hdl-45 chol/hd-3.6 ldlcalc-91 brief hospital course: a/p: 72 m w/ htn, cri, asthma, and nasal polyps referred prior to cardiac catheterization for asa desensitization following a positive ett. he has samter's syndrome given h/o asthma, nasal polyp's and aspirin allergy. he underwent aspirin desensitization per protocol and tolerated this well. it was emphasized he will need to consistently and reliably take an aspirin daily and that if he misses a dose, he could potentially have an adverse reaction such as anaphylaxis to aspirin or nsaid's. . regarding his cad, inferolateral ekg changes with exercise and preliminary mibi images, isolated inferior q on ecg suggest lcx vs. rca disease. he was hydrated for cardiac catherization and pre=treated with mucomyst for renal protection given his history of chronic renal insufficiency. he then underwent cardiac cath which showed 50% stenoses in the mid and distal lad, lcx with mild insignificant plaque and rca with an 80% mid-vessel stenosis and a 50% stenosis at the pda/plv bifurcation. he underwent placement of a drug eluting stent in his rca. no complications form the catheterization procedure. he was started on full dose aspirin and plavix and was continued on these medications at time of discharge. medications on admission: toprol xl 50mg qhs monopril 40mg daily diazide 37.5/25 (triamterene/hctz) fosamax 70mg daily advair 250/50 1 puff daily albuterol inh prn nasonex 1 sprah in am prednisone 2.5mg qod oscal +d 600 [**hospital1 **] tylenol 1gram qam/qpm aleve 440mg aam/apm discharge medications: 1. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. metoprolol succinate 50 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po hs (at bedtime). 3. monopril 40 mg tablet sig: one (1) tablet po once a day. 4. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation daily (daily). 5. prednisone 2.5 mg tablet sig: one (1) tablet po every other day (every other day). 6. fluticasone 50 mcg/actuation spray, suspension sig: one (1) spray nasal daily (daily). 7. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* discharge disposition: home discharge diagnosis: coronary artery disease aspirin allergy hypertension chronic renal insufficency discharge condition: stable discharge instructions: you were admitted to the hospital for aspirin desensitization procedure prior to cardiac catheterization. this procedure was successful. cardiac catheterization showed a partial blockage in one of your coronary arteries that supplies blood to your heart and a stent was placed to help open this blood vessel. the following changes were made to your medications: 1) started plavix 75mg daily - this should be continued for at least 1 year 2) started aspirin 325mg daily. because of your allergy, you need to make sure to take this every day. if you miss more than a few days of aspirin your allergy might return. followup instructions: please follow up with your cardiologist dr. [**first name4 (namepattern1) 8797**] [**last name (namepattern1) 23246**] in 1 month. an appointment has been made for you on [**5-28**] at 1:15pm. please call [**telephone/fax (1) 82345**] with questions. please follow up with your pcp as needed. completed by:[**2134-5-10**]",1
107,"admission date: [**2189-1-20**] discharge date: [**2189-2-16**] date of birth: [**2121-4-26**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**last name (namepattern4) 290**] chief complaint: pneumonia major surgical or invasive procedure: hemodialysis initiation paracentesis thoracentesis history of present illness: hpi: mr. [**known lastname **] is a 67 y.o. male with cryptogenic cirrhosis and hepatorenal syndrome presented to outside hospital with incrasing abdominal girth. he has also experienced increasing shortness of breath and right flank pain similar to his prior symptoms due to increased ascities. he was [**hospital 82065**] [**hospital3 8834**] and had his ascities tapped today, approx 5000 ml (turbid serosanguineous) taken out. his cxr was suspicious for multifocal pna. his lab tests there were hct 30.3, plt 193, wbc 12.1, pt 17, inr 1.7, glu 136, bun 61, cr 3.8, na 134, k 5.7, cl 102, bicarb 17, ca 9.3, prot 6.1, alb 3.6, bili 1.8, alk phos 353, alt 20, ast 60, amylase 58, lipase 112. his creatine trended upto 4.7 today per discharge summary. he was treated with zosyn 2.25 grams iv q8h, cipro 250 mg daily, midodrine 5 mg tid, prilosec 20 mg daily, carafate 1 gram qid, sodium bicarb 650 mg [**hospital1 **], lactulose 10 grams [**hospital1 **], dilaudid 1 mg q3h, vitamin k 5 mg oral. he was afebrile at osh with stable vital signs per verbal report. on arrival to micu his vitals were hr 106 bp 112/50 rr 22 96% on 4lnc. temp was not measured. patient states that his symptoms improved after the paracentesis. past medical history: - cryptogenic cirrhosis; heterozygous for hfe gene mutation and liver biopsy with marked iron deposition; grade i varices s/p banding [**10/2188**]; listed for transplant (currently inactive given his pneumonia) - recent hepatorenal syndrome with rising creatinine - left carotid endarterectomy on [**2189-1-13**] with dr. [**last name (stitle) **] - known left-sided chylothorax per thoracentesis [**12/2188**] - nephrolithiasis s/p surgical stone extraction social history: patient denies current alcohol, tobacco or illicit drug use. he reports prior, social alcohol use and infrequent tobacco use. he has no tattoos or piercings and also denies a history of blood transfusions. he is self-employed, working in sales. family history: nephew with hemachromatosis, otherwise no family history of liver disease. father died from prostate ca and mother died from cad. two sisters died from cad. two brothers alive with cardiac problems. 3 daughters alive and well. physical exam: admission exam vitals: hr 106 bp 112/50 rr 22 96% on 4lnc general: pleasant gentleman in no acute distress, following commands heent: mmm, eom-i, sclerae anicteric neck: supple, jvp 8-9 cm cor: s1s2, regular tachycardic lungs: left base > right base crackles, no wheezing abd: distended but soft, nontender, hypoactive bowel sounds ext: 3+ pitting edema bilaterally, feet warm, cellulitis in left lower extremity, right elbow abrasion. neuro: aox3, strength 5/5, sensation is intact. no asterixis skin: no jaundice, multiple skin tears discharge exam: patient deceased pertinent results: [**2189-1-20**] 09:35pm pt-28.5* ptt-46.0* inr(pt)-2.9* [**2189-1-20**] 09:35pm plt count-228 [**2189-1-20**] 09:35pm neuts-82* bands-3 lymphs-7* monos-8 eos-0 basos-0 atyps-0 metas-0 myelos-0 [**2189-1-20**] 09:35pm wbc-17.5* rbc-2.86* hgb-10.2* hct-31.5* mcv-110* mch-35.5* mchc-32.2 rdw-18.8* [**2189-1-20**] 09:35pm albumin-3.6 calcium-10.2 phosphate-6.0*# magnesium-2.3 [**2189-1-20**] 09:35pm alt(sgpt)-221* ast(sgot)-1452* ld(ldh)-1412* alk phos-337* tot bili-2.5* [**2189-1-20**] 09:35pm estgfr-using this [**2189-1-20**] 09:35pm glucose-57* urea n-72* creat-5.2*# sodium-138 potassium-6.9* chloride-102 total co2-19* anion gap-24* [**2189-1-22**] 02:07am blood wbc-14.0* rbc-2.50* hgb-8.9* hct-26.8* mcv-107* mch-35.7* mchc-33.3 rdw-19.0* plt ct-139* [**2189-1-22**] 02:07am blood pt-33.6* ptt-56.8* inr(pt)-3.5* [**2189-1-22**] 02:07am blood plt smr-low plt ct-139* [**2189-1-22**] 02:07am blood glucose-128* urean-82* creat-5.8* na-141 k-4.2 cl-103 hco3-21* angap-21* [**2189-1-20**] 09:35pm blood alt-221* ast-1452* ld(ldh)-1412* alkphos-337* totbili-2.5* [**2189-1-21**] 06:58am blood alt-177* ast-1137* ld(ldh)-827* alkphos-230* totbili-1.9* [**2189-1-22**] 02:07am blood alt-107* ast-358* ld(ldh)-270* ck(cpk)-38 alkphos-222* totbili-1.7* [**2189-1-22**] 02:07am blood albumin-3.8 calcium-9.7 phos-5.6* mg-2.2 . [**2189-1-21**] 3:41 pm peritoneal fluid gram stain (final [**2189-1-21**]): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (preliminary): no growth. anaerobic culture (preliminary): . [**2189-1-21**] 4:29 pm urine source: cvs. **final report [**2189-1-22**]** urine culture (final [**2189-1-22**]): yeast. >100,000 organisms/ml.. . [**2189-1-21**] 4:29 pm urine source: cvs. **final report [**2189-1-22**]** legionella urinary antigen (final [**2189-1-22**]): negative for legionella serogroup 1 antigen. (reference range-negative). performed by immunochromogenic assay. a negative result does not rule out infection due to other l. pneumophila serogroups or other legionella species. furthermore, in infected patients the excretion of antigen in urine may vary. . [**1-20**] cxr: portable ap chest radiograph: new right mid lung perihilar consolidation. oblique sharp margin seen in the left lower chest is frequently assigned to collapse of left lower lobe. however, no heart border can be identified, the appearance is similar in prior studies, and there is no displacement of the heart. therefore, we would like to think that this sharp margin probably does not represent lung collapse. . [**1-21**] liver us findings: as before, the liver is diffusely nodular and heterogeneous in architecture, in keeping with cirrhosis. there is a large amount of ascites. incidental note is also made of a left pleural effusion. the spleen measures 10.6 cm in length. there is no intra- or extrahepatic biliary dilatation. the common bile duct measures 4 mm, unchanged. main portal vein, left portal vein, and right portal vein are all patent, and demonstrate normal waveform and flow direction. left, middle, and right hepatic veins are patent and demonstrate normal flow direction. ivc is unremarkable. hepatic arteries are patent and demonstrate normal waveforms. splenic vein is patent. impression: 1. patent and normal-appearing hepatic vessels. 2. cirrhosis with large amount of ascites. 3. left pleural effusion . [**1-21**] renal us: findings: comparison made to [**2189-1-8**]. right kidney measures 11.3 cm, left kidney measures 10.5 cm. cyst in the upper pole of the left kidney measuring 2.1 x 1.5 x 1.4 cm is not significantly changed. there is no solid mass, stone, or hydronephrosis in either kidney. there is a large amount of ascites throughout the abdomen. color doppler evaluation of both kidneys shows normal color flow and arterial waveforms. impression: 1. no hydronephrosis. no evidence of renal artery stenosis. 2. large volume ascites. . [**1-22**] cxr: in comparison with study of [**1-20**], the moderate left pleural effusion persists. right upper lobe consolidation is similar in appearance to the previous study. left basilar atelectasis is unchanged. . [**1-26**] ct abd, chest: 1. multiple tiny hepatic non-enhancing hypodensities are consistent with cirrhosis although small hepatic abscesses can not be excluded (in the absence of prior studies to suggest stability). 2. right upper lobe opacification with consolidation worse posteriorly suggests pneumonitis from aspiration or infection. 3. persistent multifocal ground-glass opacification in the right lower lobe; the etiology can be infectious or inflammatory. 4. large left pleural effusion with associated relaxation atelectasis. 5. persistent significant ascites, cirrhosis. 6. engorgement of mesenteric vessels. . [**1-30**] cxr: overall unchanged compared to prior study, with moderate-sized left pleural effusion associated with left basilar atelectasis. brief hospital course: 67 y.o. male with cryptogenic cirrhosis, likely due to alpha-1-antitrypsin deficiency (per biopsy) and hemochromatosis, complicated by hepatorenal syndrome was admitted to osh with pna and transfered here for further evaluation. # fungemia (icu course): the patient was transferred to the icu for sepsis and hemodynamic instability. he was intubated and ventilated with central access obtained. he was found to be fungemic. treatment was initated, however the family was consulted and directed our team to withdraw care. # pneumonia: transfered from osh for cxr with multifocal pna. hap given recent admission. hemodynamically stable on arrival, sating in mid 90s on 4 l nc. cxr with r upper/middle lobe infiltrate. by day of transfer patient had o2 sat 99% on 2l, significantly better than on admission. he has cp with coughing localized to r ribs, had significant fall at osh when getting out of bed and landed on right side. it is possible that the cxr finding reflect a contusion from fall and not pneumonia. sputum culture with yeast. urine legionella negative. treated with vanc, zosyn, and fluconazole for two weeks. the pt's symptoms resolved, as did the consolidation on cxr. however, mr. [**known lastname **] had a persistant, left-sided pleural effusion. due to persistent episodes of sob, pt. underwent thoracentesis w/ 1.8l removal. fluid showed chylous transudative materarial, consistent w/ hepatic hydrothorax. # l. effusion. pt. w/o overt signs of infection, but continued to have episodes or respiratory distress including dyspnea, felt to be [**3-9**] hepatic hydrothorax. as pt. continued to experience respiratory distress episodes of tachypnea, and sob, he underwent a therpaeutic and diagnostic thoracentesis on [**2189-2-8**]. fluid was transudative, w/ 58 wbcs, 7 polys, 23 meso, 43 macro and > 14k rbcs, chylous, cytology was pending at time of discharge. pt. developed small l pntx, persistent on cxr on post thoracentesis day 1, on discharge this had resolved. patient will require a repeat ct of chest in 4wks to assess for resolution of rul pna and l effusion. # tachycardia. pt had persistently elevated hr in 100-110 during floor stay. he was ruled out for pe w/ cta, which showed slightly worsened rul opacification (see below). there was no chest pain, no changes in ecg. he completed abx course as above and there were no signs of infection, w/ [**female first name (un) 576**]/para results negative for infection after initial pna was treated. pain was adequately controlled. despite tachycardia, patient was he denied palpitations. # respiratory distress episodes. pt. w/ dyspnea, tachypnea, wheezing and tachycardia on occasions and during hd. these episodes ceased temporarily after thoracentesis on [**2189-2-8**], however recurred by [**2189-2-10**]. they were felt to be related to the rul lesion, l effusion and massive ascites. pt. had emphysematous changes on cxrs. due to continued sob, patient underwent another therapeutic paracentesis on [**2189-2-11**] with improvement in symptoms. mr. [**known lastname **] was started on ipratropium nebulizers while treated for pna and xopenex was added on [**2189-2-7**]. echo w/ bubble study was performed to assess for intrapulmonary shunting and reassessment of pulmonary hypertension as possible causes of dyspnea episodes. # hepatorenal syndrome: patient currently on both the liver and kidney transplant lists. serum creatinine on recent discharge from [**hospital1 18**] was 3.8 with bun of 60. he was treated with midodrine as outpatient. on admission cr was over 5, it was unclear if this was purely hrs or if this represented intrinsic kidney insult. uop steadily declined during admission and cr peaked at 6.7. renal us [**1-21**] was normal. pt did not respond to fluid challenge and hrs was diagnosed. pt was treated for hrs with midodrine 10mg tid, octreotide (200mg q8h), and albumin until dialysis. a r tunneled line was placed on [**1-23**] followed by hd as transition to transplant. bps improved, thus midodrine and ocreotide were discontinued. mr. [**known lastname **] had two episodes of hypotension to sbp in 70s during dialysis and was thus restarted on midodrine in am prior to dialisis. the first, on [**1-26**], was associated with dyspnea and diaphoresis. his infectious work-up was negative. he received a diagnostic and therapeutic paracenteses that afternoon, while led to complete relief of his symptoms and increase in his bp. on [**1-31**], the pt had hypotension to sbp 70s while attempting to take fluid off - he was given albumin and his bp recovered. pt. continued to receive midodrine and albumin prior to each dialysis session. his meld ranged 27-30 through most of his hospitalization. sbps were in 90-110 range. pt. was arranged for hd on t/t/saturday as op (please see discharge plan). for hyperphosphatemia patient was started on ca acetate. in addition he was started on nephrocaps. pt. is on sbp prophylaxis. # abdominal pain/cirrhosis: secondary to cryptogenic/alpha-1-antitrypsin/hemochromatosis cirrhosis. pt was accepted to liver and kidney transplant lists. paracentesis [**1-27**] showed no sbp; 7.5l taken off. para [**2-4**] no sbp; 5.5l taken off, while paracentesis on [**2-11**] was performed w/ 5l removal. these procedure also led to resolution of the pt's abdominal pain, indicating that the distension was his trigger. pt's cirrhosis confirmed on ct and continued to have elevated lfts throughout his stay. his tbili ranged from 1.5 to 3.0; his inr ranged from 1.9 to 3.7. ppd was negative and hbsag, hbcab were also negative. hbsab intermediate. hcv neg. his meld ranged 27-30 through most of his hospitalization. pt. is to follow up with liver clinic within 1wk of discharge from [**hospital1 18**]. # anemia. macrocytic. on admission, hct decreased from 31.5 -> 23.6. likely a dilutional effect in addition to rectal bleeding. the pt has confirmed internal hemorrhoids, small av malformations [**10-13**] on c-scope, and had several episodes of brbpr prior to admission and early in the admission. his hct stayed in the 25-30% throughout his admission. he did not require transfusions. the stool guaiacs during the second half of his stay were negative for blood. folate, b12 were nl. tsh was mildly high, 6.6 and free t4 was marginally low 0.91 (lower limit of nl 0.93). this decrease was felt not significant enough to account for anemia. # nurtition. patient w/ poor nutritional status and irregular intake of caloric requirement. albumin was 3.1 on admission. due to this, he required placement of post pyloric tube placed on [**2189-2-9**] with required tube feeds, nutren renal full strength at 40 ml/hr, w/ 50 ml water flushes q4h. # peripheral arterial disease: s/p recent left carotid endarterectomy [**2189-1-13**]; no active issues; outpatient follow-up. medications on admission: medications on transfer: zosyn 2.25 grams iv q8h ciprofloxacin 250 mg daily midodrine 5 mg tid prilosec 20 mg daily carafate 1 gram qid sodium bicarb 650 mg [**hospital1 **] lactulose 10 grams [**hospital1 **] dilaudid 1 mg q3h vitamin k 5 mg oral. . allergies/adverse reactions: nkda discharge medications: 1. 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* 2. midodrine 5 mg tablet sig: two (2) tablet po 7am on days of dialysis (). disp:*30 tablet(s)* refills:*2* 3. lactulose 10 gram/15 ml syrup sig: 15-45 mls po tid (3 times a day): titrate to [**4-8**] bowel movements daily. disp:*5 bottles* refills:*10* 4. ciprofloxacin 750 mg tablet sig: one (1) tablet po qfriday. disp:*12 tablet(s)* refills:*2* 5. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 6. albumin, human 25 % 25 % parenteral solution sig: 12.5 mg intravenous q dialisis. 7. epogen 4,000 unit/ml solution sig: one (1) ml injection q dialisis. 8. outpatient lab work cbc with differential, chem 10, ast, alt, total bilirubin, albumin, pt/ptt/inr, to be drawn at eod or at discretion of rehabilitation physician. 9. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 10. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 11. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical [**hospital1 **] (2 times a day) as needed for itchyness. 12. calcium acetate 667 mg capsule sig: two (2) capsule po tid w/meals (3 times a day with meals). discharge disposition: expired discharge diagnosis: primary diagnoses: - cirrhosis, likely from alpha-1-antitrypsin deficiency and hemochromatosis - hepatorenal syndrome - l-sided pleural effusion - hospital-acquired pneumonia . secondary diagnoses: - peripheral vascular disease discharge condition: deceased [**initials (namepattern4) **] [**last name (namepattern4) **] [**name8 (md) **] md [**md number(1) 292**]",0
108,"admission date: [**2153-2-8**] discharge date: [**2153-2-23**] date of birth: [**2088-11-28**] sex: m service: medicine allergies: codeine attending:[**first name3 (lf) 2745**] chief complaint: epigastric pain, n/v major surgical or invasive procedure: intubation rij central line nj tube right great toe (mtp) joint aspiration history of present illness: the patient is a 64 y.o. male with history of alcohol abuse who presented to the ed on [**2-8**] with a 1 day history of epigastric pain consistent with pancreatitis. he presented with acute onset of [**7-15**] sharp pain across his epigastrium that radiated to his back after eating a bagel on the day prior to admission. the pain was worse with inspiration. he also complained of nasuea/vomiting and diarrhea, and was unable to tolerate pos. his wife reported that he had hematemesis at home. he had never had a pain like this before. his last alcoholic drink was the day of admission ([**2-8**]). . in the ed, his vitals were temp 98.2, bp 140/83, hr 124, rr 18, and sao2 98% on ra. given the patient's history of alcohol abuse, he was given ativan 2 mg iv x8. he was also given morphine 2 mg iv x1 and 4 mg iv x1, and zofran 4 mg iv x1. labs were significant for wbc 12.5 with 91% neutrophils, cr 2.3, ast 405/alt 243/alk phos 173/t bili 4.4, amylase 1073/lipase 5586, lactate 4.1. liver/gallbladder ultrasound showed increased echogenicity of the liver indicating fatty infiltration, and no evidence of gallbladder wall edema or thickening, but the gallbladder was not completely decompressed. ct abdomen/pelvis showed no evidence for hepatitc mass or pancreatitis on the noncontrast study, likely new bibasilar aspiration worse on the right, diffuse fatty liver, and spondylotlisthesis with bilateral pars defects at l5. the patient became obtunded and was started on 7 l ivf ns, levofloxacin 500 mg iv x1, flagyl 500 mg iv x1, and clincamycin 600 mg iv x1. he was intubated for airway protection, but cxr showed that the ett was at the level of the carina. the ett was pulled back, but the patient desatted to the 60x-70s and his bp dropped to 83/53. gastric contents were being suctioned, and there was concern that the ett was in the esophagus. ct head showed no acute intracranial process. he was thus urgently reintubated by anesthesia and started on levophed gtt with bp up to 101/68 before being admitted to the micu. . in the micu, he was initially made npo, and given ivf for his pancreatitis, hypotension, and arf (likely prerenal). blood cultures showed [**3-9**] [**last name (lf) 77756**], [**first name3 (lf) **] he was started on zosyn. this speciated to an e. coli bactermia, and his antibiotic was changed to ciprofloxacin. he developed diarrhea in the micu, so c. diff was checked and was negative x2. he briefly was placed on tube feeds via an njt. on initial attempts to extubate, patient did not have a cuff-leak and was treated with decadron. patient was successfully extubated on [**2-11**] and had a speech and swallow evaluation which recommended po nectar thick liquids and soft solid consistencies. patient's abdominal pain has resolved, and pancreatic enzymes trended down. he was continued on ciwa scale for alcohol withdrawal and required valium prn. . he currently denies abdominal pain, fevers/chills, tremulousness, sob, cough, and difficulty swallowing. he is tolerating po. his last bm was 2 days ago. he reports that he is interested in an outpatient etoh treatment program. past medical history: hypertension glaucoma etoh abuse social history: patient reports drinking approximately 4 glasses of rum and coke every night, starting around 6 pm. he started drinking alcohol at the age of 17. he answered ""no"" to all screening questions of cage. he reports a former history of tobacco use, having stopped 9 years ago. he previously smoked 1ppd. he denies any illicit drug use. he is a veteran marine and served in the [**country 3992**] war. he retired 6 months ago. since he retired, he has become disinterested in things and has been drinking with increased frequency. he lives at home with his second wife. [**name (ni) **] has 16 grandchildren. family history: mother had dm and died of an mi at age 79. father died of lung cancer (occupational exposure - worked in a factory) at age 79. brother has dm. physical exam: micu admission physical exam: tm 100.4 tc 98.4 hr 72-86 bp 124/79 ac 500 x 24 fio2 0.50 peep 5.0 o2 sat 100% gen: intubated and sedated heent: mm dry, op clear heart: slightly tachy, s1s2, no gmr lungs: cta anteriorly, no rrw abd: mild tenderness to palpation in the epigastric region (patient winced slightly) ext: no cce/ wwp . medicine floor admission physical exam: t: 97.4 bp: 136/80 p: 68 rr: 20 sao2 100% on 1l, wt 191.3 lbs, fsbg 97, ciwa 0 gen: awake, alert, nad heent: nc/at; perrla, eomi; op clear with poor dentition, mmm, no submandibular, anterior cervical, or supraclavicular lad. cv: regular rate, nl s1, s2, no murmurs/rubs/gallops resp: lungs cta bilaterally, no no wheezes, rhonchi, rales. abd: + bs, soft, nt, nd abdomen, no hsm, no rebound or guarding ext: no lower extremity edema, extremities warm and well perfused. no asterixis. pertinent results: labs: admission: wbc 12.5, hct 36.6, mcv 104, plt 243 diff: 91% neutrophils, 5% lymphs, 4% monos, 0.1% eos pt 10.8, ptt 19.3, inr 0.9 na 135, k 3.4, cl 96, hco3 21, bun 31, cr 2.3, glucose 227 ca 9.4, mg 1.5, phos 2.9 alt 243, ast 405, ldh 415, alk phos 173, t bili 4.4 amylase 1073, lipase 5586 tot protein 8.4, albumin 4.8, globulin 3.6 ck 209, 164, 140. ck-mb 2, 3, 3 trop t <0.01, <0.01, 0.02 ammonia 27 hbsag, hbsab, hbcab, hav ab, hcv ab negative serum tox negative for asa, etoh, acetmnp, bzd, barbitr, tricycl lactate 4.1, 1.2, 0.9 abg: 7.31/38/487 (intubated) ua: clear, sp [**last name (un) **] 1.019, tr blood, neg nitrite, tr protein, neg glucose, neg ketone, mod bilirub, 12 urobiln, neg leuk, mod bacteria, 0-2 wbc, 0-2 epis ucr 53, una 211, uosm 573 urine tox: negative bzd, barbitr, cocaine, amphetm, mthdone. positive opiates urine eos ([**2-21**]): negative esr 130, crp 31.9 ret aut 2.4 fe 24, tibc 203, fferritin 845, trf 156, vit b12 476, folate 8.9 discharge labs: wbc 5.7, hct 23.4, mcv 98, plt 516 na 140, k 4.2, cl 108, hco3 23, bun 9, cr 1.5, glucose 82 ca 8.5, mg 1.8, phos 3.5 alt 17, ast 24, ldh 183, alk phos 51, t bili 0.4 amylase 206, lipase 351 . micro: blood cx ([**2-8**]): blood culture, routine (final [**2153-2-11**]): escherichia coli. final sensitivities. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ <=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 meropenem-------------<=0.25 s piperacillin---------- <=4 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s aerobic bottle gram stain (final [**2153-2-9**]): gram negative rod(s). anaerobic bottle gram stain (final [**2153-2-9**]): gram negative rod(s). . blood cx ([**2-9**] x2, [**2-10**], [**2-11**], [**2-14**], [**2-15**], [**2-16**] x2): no growth . blood cx ([**2-21**] x2): ngtd . urine cx ([**2-8**], [**2-21**]): no growth . urine cx ([**2-15**]): staphylococcus, coagulase negative. 10,000-100,000 organisms/ml. . urine cx ([**2-16**], [**2-21**]): <10,000 organisms/ml . stool cx ([**2-10**], [**2-11**], [**2-13**]): c. diff negative x3 . joint fluid cx, right 1st mtp joint ([**2-14**]): gram stain (final [**2153-2-14**]): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final [**2153-2-17**]): no growth. . chest pustule cx ([**2-22**]): gram stain (final [**2153-2-22**]): no polymorphonuclear leukocytes seen. no microorganisms seen. wound culture (final [**2153-2-24**]): staphylococcus, coagulase negative. rare growth. fungal culture (preliminary): no fungus isolated. a swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. a negative result should be interpreted with caution. whenever possible tissue biopsy or aspirated fluid should be submitted. anaerobic culture (final [**2153-2-26**]): no anaerobes isolated. . imaging: ecg ([**2-8**]): sinus tachycardia at a rate of 112. diffuse non-specific st-t wave changes. no previous tracing available for comparison. . liver/gallbladder ultrasound ([**2-8**]): impression: 1. limited imaging of the liver shows increased echogenicity indicating fatty infiltration. of note, more serious forms of liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 2. no evidence of gallbladder wall edema or thickening; however, the gallbladder is not completely decompressed. if there is continued clinical concern for acute cholecystitis, a nuclear medicine gallbladder scan may be performed. . ct abdomen/pelvis ([**2-8**]): ct abdomen and pelvis without iv contrast: in the lungs, there are bibasilar opacification with air bronchograms on the right, likely representing aspiration. the visualized portion of the heart and great vessels appears essentially normal, although there are vascular calcifications. in the abdomen, the spleen is normal and an incidental note is made of a splenule. the kidneys are small and there is some mild, non-specific perirenal fat stranding. the liver is diffusely fatty, but there is no focal parenchymal mass identified on this noncontrast scan. allowing for the lack of iv contrast, the gallbladder, adrenals, pancreas, stomach, duodenum and small bowel appear normal. there is no free air, free fluid or abdominal lymphadenopathy. in the pelvis, the pelvic loops of bowel appear normal excepting for sigmoid diverticulosis without evidence of diverticulitis. a foley catheter is in place and the bladder appears normal. there are prostatic calcifications and the seminal vesicles appear normal. no pelvic free fluid, free air or lymphadenopathy is identified. osseous structures: no suspicious lytic or blastic lesions. there is grade i anterolisthesis of l5 on s1 and associated bilateral spondylolysis. impression: 1. likely new aspiration bibasilar, worse on the right. 2. no evidence for hepatic mass or pancreatitis on this noncontrast study. 3. diffuse fatty liver. 4. spondylolisthesis with bilateral pars defects at l5. . ct head ([**2-8**]): there is no intracranial hemorrhage. an old right caudate lacunar infarct is seen. there is no shift of normally midline structures, loss of [**doctor last name 352**]-white matter differentiation, abnormality in size or contour of ventricles, or gross osseous abnormality. mastoid air cells are clear. there is mild sinonasal thickening of the ethmoid air cells. impression: no acute intracranial process. . cxr portable ([**2-8**]): impression: 1. non-standard position of ett; needs to be withdrawn. 2. og tube in standard position, although side port is at the diaphragmatic level. . cxr portable ([**2-8**]): impression: standard position of et tube and now distended stomach. . cxr portable ([**2-8**]): impression: 1. interval insertion of a right ij line with tip projecting over the right atrium; this means retraction by approximately 3 to 4 cm is recommended. 2. new right upper lobe collapse. . cxr portable ([**2-8**]): right internal jugular vascular catheter has been re-positioned, but distal tip is still slightly below the expected junction of the superior vena cava and right atrium. nasogastric tube side port remains proximal to the ge junction level and could be advanced for optimal placement. right upper lobe collapse has resolved in the interval, and there has been improvement in the degree of gastric distention. otherwise no substantial short-interval change. . cxr portable ([**2-8**]): moderate right pleural effusion has increased since earlier in the day following resolution of right upper lobe collapse. the heart size is top normal, unchanged, and there is no longer any mediastinal vascular engorgement. left lung is clear, and there is no left pleural effusion or any evidence of pneumothorax. tip of the endotracheal tube is at the thoracic inlet, and the cuff remains mildly over-inflated. nasogastric tube ends in a non-distended stomach. tip of the right internal jugular line projects over the superior cavoatrial junction. . cxr portable ([**2-9**]): tip of the et tube is in standard placement, below the thoracic inlet, approximately 5 cm above carina. nasogastric tube passes into the stomach and tip of a right jugular line in the upper right atrium. small right pleural effusion is still present. heart size mildly enlarged, and mediastinal veins are still engorged. left lung is clear. no evidence of pneumonia or lobar collapse, and no pneumothorax is present. . cxr portable ([**2-10**]): the endotracheal tube, nasogastric tube, and right-sided central venous catheter are in unchanged position. there is cardiomegaly with some prominence in the mediastinum which is stable. there is no signs for overt pulmonary edema or focal consolidation. . cxr pa/lateral ([**2-13**]): the patient was extubated in the meantime interval with removal of the ng tube. the right internal jugular line tip terminates at the cavoatrial junction. the cardiomediastinal silhouette is stable. the right lower lobe consolidation is demonstrated, overall slightly improved since [**2153-2-10**] which might represent area of improving pneumonia/aspiration. minimal retrocardiac opacity on the left is noted most likely consistent with atelectasis. a small bilateral pleural effusion is persistent. impression: right lower lobe consolidation consistent with pneumonia/aspiration, slightly improving. left basal atelectasis. . bilateral foot films ([**2-15**]): impressions: no bony abnormalities or soft tissue calcification suggestive of gout. small bilateral plantar calcaneal spurs. . cxr pa/lateral ([**2-16**]): right lower lobe consolidation has markedly improved with subtle heterogeneous opacities remaining in the periphery of the right lower lung. no new or progressive abnormalities are identified. cardiomediastinal contours are within normal limits. small pleural effusions have decreased in size. impression: resolving right lower lobe consolidation and improving small pleural effusions. . ct abdomen/pelvis ([**2-17**]): ct abdomen with contrast: previously noted consolidation within the right lower lobe has demonstrated interval improvement with only a small amount of residual patchy opacity remaining. there is a small residual right pleural effusion and trace left effusion. the liver, stomach, spleen, splenule, adrenal glands, kidneys and collecting systems are unremarkable. the pancreas appears normal in appearance without focal abnormality or ductal dilatation. intra-abdominal loops of small and large bowel are normal in appearance. no free fluid or free air is identified in the abdomen. there are several tiny lymph nodes in the paraaortic region. calcified and irregular atherosclerotic plaque is detected within the descending abdominal aorta and iliac branches without aneurysmal dilatation. ct pelvis with contrast: the bladder demonstrates a small amount of intraluminal air, consistent with recent foley catheterization detected on previous study. there is a small bladder outpouching in the left lateral aspect suggesting a diverticulum. the distal ureters, rectum, and seminal vesicles are normal in appearance. there is a small amount of calcification within the prostate gland, which is otherwise unremarkable. no inguinal or iliac adenopathy is identified. osseous structures: there is a synovial herniation pit of the left femoral head. no suspicious lytic or sclerotic lesions are identified. there is grade i anterolisthesis of l5 on s1 and associated bilateral spondylolysis. impression: 1. interval improvement of bibasilar consolidations. 2. diffuse fatty liver. 3. spondylolisthesis with pars defects at l5. 4. irregular calcified atherosclerotic plaque within the abdominal aorta and iliac branches. 5. small right pleural effusion. 6. small outpouching of the left lateral bladder wall suggesting a diverticulum. . lenis ([**2-21**]): impression: no evidence of dvt of bilateral lower extremities. brief hospital course: # pancreatitis: the patient has a history of alcohol abuse, and presented with a 1 day history of acute onset [**7-15**] sharp pain across his epigastrium that radiated to his back and was associated with nausea and vomiting. labs on admission were significant for wbc 12.5 with 91% neutrophils, ast 405/alt 243/alk phos 173/t bili 4.4, amylase 1073/lipase 5586, lactate 4.1. liver/gallbladder ultrasound showed increased echogenicity of the liver indicating fatty infiltration, and no evidence of gallbladder wall edema or thickening, but the gallbladder was not completely decompressed. ct abdomen/pelvis showed no evidence for hepatic mass or pancreatitis on the noncontrast study. in the ed he received 7 l ns and was started on levofloxacin 500 mg iv x1, flagyl 500 mg iv x1, and clincamycin 600 mg iv x1. he had at least 6 [**last name (un) 5063**] criteria (he did not have an abg in 48 hours). he was intially sent to the micu as he had been intubated for airway protection, and started on levophed gtt for hypotension. blood cultures grew [**3-9**] e. coli, which was thought to be from translocation from the pancreatitis. he was treated with ivf and zosyn->ciprofloxacin. he was initially made npo, briefly placed on tube feeds via an njt, and then started on a regular diet. his amylase and lipase trended down, but then bumped back up on [**2-12**], likely due to his njt feeds being transitioned to oral food. his amylase/lipase plateaued, and his abdominal pain ressolved. he was continued on a regular low fat diet. he continued to spike fevers, and a repeat ct abdomen/pelvis showed that the pancreas appeared normal in appearance without focal abnormality or ductal dilatation. his amylase was 206 and his lipase was 351 on discharge. . # e. coli bacteremia: blood cultures on admission showed [**3-9**] bottles of pansenstive e. coli, which was thought to be secondary to translocation from the pancreatitis. he was treated with zosyn->ciprofloxacin 500 mg [**hospital1 **] for a 13 day course (he was stopped 1 day short of a 14 day course as ciprofloxacin may have been contributing to a drug fever, see below). surveillance blood cultures showed no growth and ngtd. . # fevers: since [**2-12**], the patient would spike fevers to 101 each evening around midnight. this was not likely due to recurrence of e. coli bacteremia as subsequent blood cultures had shown no growth. repeat ct abdomen/pelvis had shown that the pancreas appears normal in appearance without focal abnormality or ductal dilatation. esr was elevated to 130, and crp was 31.9. ddx included drug fever (cipro and colchicine were new), gout, atelectasis, aspiration pna, aspiration pneumonitis, dvt, and endocarditis (no murmur on exam). rheumatology was reconsulted and determined that there were no findings suggestive of synovitis, periarthritis, or discitis on joint exam. dermatology was consulted to evaluate the papules on his chest and determined that he has several follicularly based papules and pustules which appear to be consistent with folliculitis, and this does not appear to be a disseminated fungal infection as he is well appearing, immunocompetent, with negative blood cultures. pustule culture showed rare growth of staph coag negative and no fungus isolated. the repeat ct abdomen pelvis did show a small residual right pleural effusion and trace left effusion, but the team did not decide to tap it given it would likely be low yield. lenis were negative for dvt bilaterally. id was consulted for the persistent fever, and determined that it was most likely a drug fever, but urine eos were negative. ciprofloxacin was discontinued after a 13 day course. the team decided not to continue thiamine, folate, mvi, and feso4 upon discharge, as these new medications may be contributing to his drug fever. they can be added back on as an outpatient when his fevers ressolve. . # gout: on [**2-14**], the patient developed right great toe pain. he reported that he intermittently gets this pain in his right great toe, but denies arthritis in his ankles, knees, or elbows. he has no foot hardware in place. he has a history of alcohol abuse putting him at risk for gout. he did have an e. coli bacteremia on admission putting him as risk for a septic joint, but had subsequent negative surveillance blood cultures. his right first mtp was erythematous and swollen on exam. the joint was tapped by rheumatology, and found to have 2 cc serosanguenous turbid fluid, with intra- and extra-cellular needle shaped crystals, which were negatively birefringent consistent with monosodium urate. gram stain showed 1+ pmns but no microorganisms, and joint culture showed no growth. plain film of his bilateral feet showed no bony abnormalities or soft tissue calcification suggestive of gout and small bilateral plantar calcaneal spurs. he was started on colchicine 0.6 daily for 1 week, then every other day until rheumatology follow up. his hctz was discontinued, and he was encouraged to abstain from etoh abuse. the patient had another gout flare on the evening prior to discharge (and spiked a low grade temp to 100.5), so rheumatology was notified and will call him in a few days to see how he is doing. he will follow up with rheumatology in 4 weeks, and will likely need to start allopurinol at that time. . # alcohol abuse/withdrawal: the patient has a history of drinking approximately 4 glasses of rum and coke every night. in the micu, he was maintained on versed while intubated, and then on valium per ciwa scale. during this hospitalization, he was started on thiamine, folate, and mvi. the patient was discharged home, and will follow up with an outpatient alcohol treatment program at the va. he is interested in an inpatient etoh program, but did not want to attend the one at the va since it is unsupervised at night. the patient was not discharged on thiamine, folate, and mvi, as these new medications may have been contributing to his fevers. they can be added back on later as an outpatient. . # respiratory failure/aspiration pna: the patient was initially intubated for airway protection after receiving ativan in the ed. ct abdomen/pelvis on admission showed likely new aspiration bibasilar, worse on the right. subsequent cxrs in the micu did not show any infiltrates. on initial attempts to extubate, patient did not have a cuff-leak and was treated with decadron. patient was successfully extubated on [**2-11**] and had a speech and swallow evaluation which recommended po nectar thick liquids and soft solid consistencies. repeat evaluation indicated the patient could have a regular diet with thin liquids. repeat cxr pa/lateral on [**2-13**] showed right lower lobe consolidation consistent with pneumonia slightly improving, and left basal atelectasis. . # thrombocytosis: his platelet count was 243 on admission and trended up to 617 on [**2-21**]. this may be a reactive thrombocytosis in response to an infection or even his iron deficiency. he may also have had a delayed reactive increase in platelets in response to the zosyn or cipro. his platelets did not decrease in response to 1 l ns. his platelets were 516 on discharge, and should continue to be followed as an outpatient. . # anemia: the patient's hct was 41.3 on admission, which initially dropped to 32.1 in the setting of fluid resuscitation. ng lavage in the micu was guaiac negative. his mcv was 103-106 which suggests macrocytosis in the setting of alcohol use. his hct plateaued at 23-27. his stool was guaiac negative. fe studies showed: fe 24, tibc 203 (transferrin sat 11.8%), ferritin 845, trf 156. vit b12 476, folate 8.2. hemolysis labs showed: ldh 175, t bili 0.8, retic 2.4%, hapto 164. he was started on thiamine, folate, and feso4, but he was not discharged on these medications as they may have been contributing to his drug fevers. these medications can be added back as an outpatient once his fevers ressolve. his hct was 23.4 on discharge. he was scheduled for an outpatient colonoscopy and egd. . # transaminitis: alt 243/ast 405 on admission, which is most likely secondary to alcohol abuse. ct abdomen/pelvis showed diffuse fatty liver. hav ab, hbsag, hbcag, hgcab, and hcv ab negative. . # arf: his cr was 2.3 on admission, and has trended down to 1.5-1.7. it is unclear what his baseline cr is, and his arf on admission was thought to be prerenal from third-spacing in the setting of acute pancreatitis. urine lytes: fena 4.27%, uosm 573. he was fluid resuscitated in the ed and micu, with improvement in cr to 1.5 on discharge. his renal function should be monitored closely, especially now that he is on colchicine. . # diarrhea: the patient developed diarrhea in the micu, and c. diff was negative x3. he was started on pancrease tid with meals as there may be a component of malabsorption with his pancreatitis, but he was not discharged on this medication. his subsequent diarrhea was thought to be a side effect of colchicine. . # hypertension: his hctz was discontinued in the setting of gout. his lisinopril was increased to 30 mg daily. he was started on toprol xl 100 mg daily. . # glaucoma: he was continued on cosopt and lumigan eye drops. medications on admission: medications on admission: lisinopril-hctz 20mg-12.5mg daily cosopt 2% - 0.5% eye gtts lumigan 0.03% eye gtts . allergies/adverse reactions: codeine (""feels loopy"") discharge medications: 1. lisinopril 30 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 2. cosopt ophthalmic 3. lumigan ophthalmic 4. toprol xl 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. disp:*30 tablet sustained release 24 hr(s)* refills:*2* 5. colchicine 0.6 mg tablet sig: one (1) tablet po daily (daily) for 1 weeks: take from [**date range (1) 77757**]. disp:*7 tablet(s)* refills:*0* 6. colchicine 0.6 mg tablet sig: one (1) tablet po every other day for 18 days: take every other day from [**date range (1) 77758**] (when you follow up with rheumatology). disp:*9 tablet(s)* refills:*0* discharge disposition: home with service facility: [**hospital 119**] homecare discharge diagnosis: primary: pancreatitis e. coli bacteremia respiratory failure gout alcohol withdrawal transaminitis acute renal failure diarrhea anemia . secondary: hypertension glaucoma discharge condition: stable, no abdominal pain discharge instructions: 1. if you develop increased abdominal pain, nausea/vomiting, diarrhea, inability to tolerate food or fluids, fever >101.5, increased cough, shortness of breath, chest pain, or any other symptoms that concern you, call your primary care physician or return to the ed. 2. take all medications as prescribed. 3. attend all follow up appointments. 4. your lisinopril-hydrochlorothiazide combination pill was discontinued during this hospitalization, as hydrochlorothiazide can contribute to gout. now you should take lisinopril 30 mg daily. 5. you were started on toprol xl 100 mg daily for your blood pressure. 6. you were started on colchicine 0.6 mg daily to complete a 1 week course for gout ([**date range (1) 77757**]). after that you should take colchicine 0.6 mg every other day until you follow up with rheumatology on [**3-19**]. 7. you should stop drinking alcohol, as this is contributing to your pancreatitis, gout, and other medical problems. followup instructions: you have a follow up egd (upper endoscopy) and colonoscopy (to evaluate your anemia) on [**2153-3-1**] at 11:30 with dr. [**last name (stitle) **] ([**telephone/fax (1) 463**]) in gastroenterology in the [**hospital ward name 1950**] building, [**location (un) 3202**]. they will be contacting you with more information. . you have a follow up appointment with your primary care physician, [**last name (namepattern4) **]. [**last name (stitle) **] ([**telephone/fax (1) 30837**]) on [**2153-3-2**] at 11:15. . you have a follow up appointment with dr. [**last name (stitle) 12434**] in rheumatology ([**telephone/fax (1) 2226**]) on [**2153-3-19**] at 9:00 at [**last name (namepattern1) **], [**hospital unit name 3269**], [**hospital unit name **].",1
109,"admission date: [**2189-3-5**] discharge date: [**2189-3-8**] date of birth: [**2118-9-15**] sex: f service: medicine allergies: gentamicin / prednisone / lisinopril / naproxen attending:[**first name3 (lf) 45**] chief complaint: transferred for cardiac cath major surgical or invasive procedure: cardiac cath history of present illness: this is a 70 year old female with hx of htn, hyperlipidemia who was trasferred from [**hospital3 4107**] for ?nstemi and cardiac cath. patient is scheduled for hip surgery in the near future. she had donated blood in preparation for surgery several days ago. since that time, she has been feeling ""unwell"" with fatigue, nausea, small amounts of vomiting, back pain and a ""pounding chest"". she saw her pcp this morning and troponin came back at 3.13. ekg showed mild lateral st elevations so she was sent to the ed. she was given aspirin 325mg and heparin iv gtt was started. sbp was mildly low in the 90's, and she was given a bolus of normal saline. she was transferred to [**hospital1 18**] for cardiac cath, which showed clean coronaries but likely takutsobo's cardiomyopathy. given her marginal blood pressures and significant anemia, she was transferred to the ccu for further management. on arrival to the ccu, the patient was chest pain free. she denies any palpitations, diaphoresis, sob, n/v or diarrhea. she states that she feels well and has no complaints on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, surgery, cough, hemoptysis, or red stools. she does report black stools since starting ferrous sulfate. she denies recent fevers, chills or rigors. all of the other review of systems were negative. past medical history: 1. cardiac risk factors: hypertension 2. cardiac history: -cabg: none -percutaneous coronary interventions: none -pacing/icd: none 3. other past medical history: rheumatoid arthritis rheumatic fever a 9yo hyperlipidemia osteoporosis glaucoma anemia of chronic disease macular degeneration diverticulitis social history: -tobacco history: none -etoh: none -illicit drugs: none patient was born in [**country 4754**] but has lived in the states since [**2136**]., family history: no family history of cad physical exam: general: nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva with pallor dry mm. no xanthalesma. neck: supple, no jvd cardiac: rr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: ctab, no crackles, wheezes or rhonchi in anterior lung fields. abdomen: soft, ntnd. no hsm or tenderness. extremities: no c/c/e. no femoral bruits. 2+ dp, no hematoma at right femoral cath site, no tenderness skin: no stasis dermatitis, ulcers, scars, or xanthomas. pertinent results: [**2189-3-5**] 08:31pm glucose-120* urea n-9 creat-0.5 sodium-139 potassium-3.7 chloride-108 total co2-24 anion gap-11 [**2189-3-5**] 08:31pm calcium-7.9* phosphate-2.4* magnesium-1.9 [**2189-3-5**] 08:31pm wbc-10.2 rbc-3.08* hgb-8.7* hct-26.6* mcv-87 mch-28.4 mchc-32.8 rdw-16.8* [**2189-3-5**] 08:31pm plt count-165 [**2189-3-5**] 08:31pm pt-13.8* ptt-30.5 inr(pt)-1.2* [**2189-3-5**] 06:15pm glucose-138* urea n-10 creat-0.5 sodium-139 potassium-3.2* chloride-110* total co2-22 anion gap-10 [**2189-3-5**] 06:15pm ck(cpk)-120 [**2189-3-5**] 06:15pm wbc-10.8 rbc-2.77* hgb-7.8* hct-23.5* mcv-85 mch-28.1 mchc-33.2 rdw-16.9* [**2189-3-5**] 06:15pm plt count-153 [**2189-3-5**] 06:15pm pt-15.1* inr(pt)-1.3* ekg [**2189-3-5**] ([**hospital1 **]): sinus tachycardia, 1mm ste v5-v6 cxr [**2189-3-5**] ([**hospital1 **] report): the heart size is within normal limits. the lungs are clear. there is no pleural fluid or ptx. cardiac cath [**2189-3-5**]: lmca: normal lad: normal lcx: normal rca: normal -- lv apical akinesis consistent with takutsobo's cardiomyopathy. elevated right and left heart filling pressures with preserved cardiac output. marked anemia. rvedp 4, pcwp 15, lvedp 15 tte [**2189-3-6**]: the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is moderate regional left ventricular systolic dysfunction with hypokinesis of the mid-lv segments and akinesis of the distal segments and apex. the basal lv segments contract normally (lvef = 30-35%). no masses or thrombi are seen in the left ventricle. 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. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no systolic anterior motion of the mitral valve leaflets. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: no outflow tract obstruction. moderate regional left ventricular systolic dysfunction. no lv thrombus seen. in absence of obstructive coronary artery disease, these findings are consistent with takotsubo-type cardiomyopathy. if clinically indicated, recommend a repeat study in [**2-23**] weeks to reassess wall motion abnormalities. brief hospital course: this is a 70 year old female with hx of htn who was trasferred from [**hospital3 4107**] for ?nstemi and cardiac cath, which showed clean coronaries and likely takutsobo's. # takutsobo's cardiomyopathy: on admission, the patient had a troponin elevation and lateral ecg changes concerning for acs. however her cardiac cath showed clean coronary arteries and an lv gram consistent with takutsobo's cmp. echo showed apical akinesis also consistent with the diagnosis. the patient's recent stress and blood donation in preparation of her upcoming surgery likely precipitated the illness. as the patient has an allergy to ace-i, this was not initiated. she had at first some low blood pressures so beta blocker were also held initially. she was able to be started on low dose carvedilol and valsartan, without any documented adverse reaction. she was monitored overnight for cardiogenic shock and remained stable in the ccu. she was transferred to the cardiology floor. she was also initiated on warfarin for the risk of thrombus with apical akinesis. she will follow up with a new outpatient cardiologist, dr. [**last name (stitle) 10543**], for repeat echo in [**12-23**] weeks, as this etiology is typically transient. at that time it will be determined if she needs to continue on anticoagulation therapy. in the meantime, she was instructed to continue asa, coumadin, carvedilol and valsartan, as well as stick to a low salt diet. # anemia: hct 23.5 s/p cardiac cath, unknown baseline. anemia was likely [**12-22**] recent blood donation and s/p cardiac cath along with hemodilution from ivf given at osh. given recent troponin leak, patient was transfused two units prbcs. afterwards her hct remained stable. # hypotension: patient with sbp of 90 on admission. likely her blood pressure was low in the setting of takutsobo's cmp. she was given two units prbcs as above. held beta blockers and ace inhibitors as above, but able to start carvedilol and valsartan. fen: cardiac diet prophylaxis: -dvt ppx with heparin sq -bowel regimen code: full code medications on admission: norvasc 5mg daily vit d 1000u daily naltrexone 4.5mg qhs magnesium citracal xalatan eye drops timolol eye drops discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. timolol maleate 0.5 % drops sig: one (1) drop ophthalmic daily (daily). 3. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 4. calcium citrate 250 mg tablet sig: one (1) tablet po twice a day. 5. vitamin d-3 400 unit tablet sig: two (2) tablet po once a day. 6. magnesium 250 mg tablet sig: two (2) tablet po once a day. 7. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. disp:*30 tablet(s)* refills:*2* 8. carvedilol 3.125 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 9. valsartan 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 10. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 2 days. disp:*4 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary diagnoses: takutsobo's cardiomyopathy with ef 30-35% anemia 2/2 blood donation hypotension discharge condition: stable vital signs, able to ambulate discharge instructions: you were admitted to [**hospital1 18**] for evaluation of elevated cardiac markers. you were found to have a syndrome called takutsobo's cardiomyopathy which was likely a result of your recent stress and blood draws for your upcoming surgery. this is a transient condition and should resolve in [**12-23**] months. . because your heart is weak, you need to monitor yourself for fluid overload. this can result in trouble breathing when you exert yourself, difficulty lying flat to sleep, swelling in the feet or hands, a dry cough or nausea. if you notice any of these symptoms, please call dr. [**first name (stitle) 1356**]. please weigh yourself every day in the morning after you get up and write down the weight. if you gaim more than 3 pounds in 1 day or 6 pounds in 3 days, call dr. [**first name (stitle) 1356**]. please follow a low sodium diet. information regarding a weak heart was reviewed with you before you were discharged. . new medicines: 1. carvedilol 3.125mg twice a day 2. valsartan 40mg once a day 3. warfarin 5mg once a day 4. ciprofloxacin 500mg twice a day for two more days . stop taking norvasc. . you should have your warfarin level checked in the next few days. you should go to your primary care doctor's office to have this level checked. . if you experience light headedness, increasing weakness, dizziness, dark or bloody stools, chest pain, shortness of breath, nausea or any other concerning symptoms please seek medical attention. followup instructions: primary care: [**last name (lf) **],[**first name3 (lf) **] m. [**telephone/fax (1) 40833**] date/time: please make an appt to see dr. [**first name (stitle) 1356**] in [**11-21**] weeks. . cardiology: please follow up with dr. [**first name4 (namepattern1) **] [**last name (namepattern1) 10543**] in the next 2-3 weeks. you will need a repeat echocardiogram at that time as well. the number to call to make an appointment is ([**telephone/fax (1) 24747**] [**first name8 (namepattern2) **] [**last name (namepattern1) **] md [**doctor first name 63**] completed by:[**2189-3-8**]",1
110,"admission date: [**2161-4-15**] discharge date: [**2161-4-17**] date of birth: [**2121-5-5**] sex: f service: neurology allergies: levaquin / azithromycin attending:[**first name3 (lf) 8850**] chief complaint: seizures while off keprra. major surgical or invasive procedure: none. history of present illness: mrs. [**known firstname **] [**known lastname **] is a very nice 39-years-old woman with metastatic nsclc to the bone and brain who recently was taken off her keppra who comes with multiple seizures. she was diagnosed with nsclc 1 year ago and received chemotherapy with gemzar and carboplatin finishing in [**2160-11-15**]. then, in [**1-23**] she was diagnosed with metastasis to the brain. she was started on keppra prophylactically as well as decadron, which was recently tappered down from 4mg four times a day to 2 mg four times a day. she had abnormal lfts, so her oncologist stopped keppra 1 week ago to see if they could improve and consider further chemotherapy. yesterday morning, she put her kids to school and went back to bed, awoke and noticed a tremor in her right hand that rapidly spreaded proximally to the rest of her body. then she tried to reach the phone, but passed out. she awoke in the floor with left frontal and parietal headache and called her sister. ems arrived and brought her to our er. patient denies any aura or loss of sphincter tone. she did not remember any more details from the event and there were no witnesses. of note, patient had recent mri showed bilateral enhancing lesions with decreased edema compared to [**month (only) 956**] [**2161**]. in the er, her vital signs were t 101.1 f, bp 129/89, hr 135, rr 20, spo2 99% on ra. patient received vancomycin and ceftriaxone (1 gram and 2 grams respecively) for a possible pneumonia or abnormal shadow on cxr. patient received tylenol. her cta was negative for pe and showed clear lungs. dr. [**last name (stitle) **] witnessed another seizure in the er and patient received ativan 1 mg iv x1 and stopped seizing. keppra was re-started at 1 gram x 1. patient also received decadron 4 mg iv x 1 and then decadron 6 mg iv x 1. patient was cultured. lft's showed alt 109, ast 29, alkphos 25, and hct 19.6. ct scan of the head showed attenuation of bilateral multiple foci of frontal and fronto-parietal enhancements. patient was admitted to the ticu, where they continued her keppra and steroids. her neuro-oncologist was consulted and requested transfer to the oncology service in the [**hospital ward name 516**] and requested consult of dr. [**first name8 (namepattern2) **] [**name (stitle) 3274**] after discussing with pts primary oncologist. vitals upon sign out: 98.9, 101, 122/72, 90-120. past medical history: past oncologic/medical history: =============================== 1. non-small cell lung cancer diagnosed via biopsy in [**month (only) 404**] [**2160**] with known metastasis to to t11. she underwent chemotherapy with gemcitabine and carboplatin from [**month (only) 956**] to [**2160-6-15**]. she presented in [**2161-1-15**] to [**hospital1 18**] with brain metastases. no neurosurgery intervention deemed apporpriate and was set up for whole brain xrt by radiation oncology at [**hospital1 18**] which she finished one week ago. patient's primary oncologist, dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] ([**telephone/fax (1) 74124**]) was planning on starting another session of chemotherapy soon as recent pet scan showed presence of lesions in chest and lung. social history: she lives with her husband and 3 children (girl 15, boys 12 and 7 all healthy). she denies smoking, alcohol or drug use. she did not have recent travel, or change in diet. she used to work in a medical office in the medical records depparment. she is currently unemployed. family history: there if no family history of cancer including lung, ovary, colon and breast. her father is alive at age 77 with hypertension. her mother is alive at age 68 healthy. she has 2 healthy sisters. there is no history of premature cad or stroke or diabetes. physical exam: vital signs: t: 96.5 f, bp: 130/74 mmhg, hr: 125, rr: 22, and 02 saturation in room air: 97%. general: nad, very pleasant woman. skin: warm and well perfused, no excoriations or lesions, rashe in her back, erythematous, blanching without any other lessions. heent: at/nc, eomi, perrla, anicteric sclera, pink conjunctiva, patent nares, mmm, good dentition, nontender supple neck, no lad, no jvd cardiac: rrr, s1/s2, no mrg lung: ctab abdomen: soft, nondistended, +bs, nontender in all quadrants, no rebound or guarding, no hepatosplenomegaly musculoskeletal: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities pulses: 2+ dp pulses bilaterally neurological examination: her karnofsky performance score is 80. her mental status is awake, alert, and oriented times 3. her language is fluent with good comprehension. her recent recall is intact. cranial nerve examination: her pupils are equal and reactive to light, from 4 mm to 2 mm bilaterally. extraocular movements are full. visual fields are full to confrontation. her face is symmetric. facial sensation is intact. hearing is intact. tongue is midline. palatae goes up in the midline. sternocleidomastoid and upper trapezius are strong. motor examination: she does not have a drift. strength is [**5-19**] at all muscle groups in the upper extremities now. her lower extremity strength is [**5-19**] at all muscle groups, except for 4+/5 strength in proximal lower extremities. her reflexes are 0 throughout, including the ankles. touch and proprioception are intact at upper and lower extremities. she does not have appendicular dysmetria or truncal ataxia. she can walk and tandem gait is fine. she does not have a romberg. pertinent results: on admission: [**2161-4-15**] 10:10am wbc-2.6* rbc-2.93*# hgb-6.2*# hct-19.6*# mcv-67* mch-21.3* mchc-31.8 rdw-17.7* [**2161-4-15**] 10:10am neuts-87* bands-0 lymphs-6* monos-7 eos-0 basos-0 atyps-0 metas-0 myelos-0 [**2161-4-15**] 10:10am hypochrom-3+ anisocyt-3+ poikilocy-2+ macrocyt-normal microcyt-3+ polychrom-2+ ovalocyt-2+ stippled-2+ teardrop-2+ [**2161-4-15**] 10:10am plt smr-very low plt count-53*# [**2161-4-15**] 10:10am pt-16.1* ptt-29.0 inr(pt)-1.4* [**2161-4-15**] 10:10am glucose-59* urea n-13 creat-0.2* sodium-146* potassium-2.1* chloride-122* total co2-19* anion gap-7* [**2161-4-15**] 10:10am alt(sgpt)-109* ast(sgot)-29 alk phos-25* tot bili-0.6 [**2161-4-15**] 10:10am lipase-55 [**2161-4-15**] 10:10am albumin-2.4* [**2161-4-15**] 10:13am lactate-0.8 [**2161-4-15**] 12:55pm urine color-straw appear-clear sp [**last name (un) 155**]-1.045* [**2161-4-15**] 12:55pm urine blood-neg nitrite-pos protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg [**2161-4-15**] 12:55pm urine rbc-0 wbc-0-2 bacteria-occ yeast-none epi-0 ct head [**2161-4-16**]: no significant interval change in the appearance of multiple foci of vasogenic edema consistent with known metastatic disease. there is no evidence for herniation or hemorrhage cta [**2161-4-16**]: 1. the study is nondiagnostic for pulmonary embolus beyond the level of the main, undivided pulmonary artery secondary to suboptimal opacification of the pulmonary arterial tree. this was communicated to dr. [**last name (stitle) 3271**] at the time the study was performed. as the patient subsequently had a seizure on the scanner table and became post-ictal, repeat study was postponed until patient is more able to follow breathing instructions. 2. multiple spiculated pulmonary nodules measuring up to 2 cm in both the upper and lower left lobes, consistent with biopsy-proven malignancy. additional small 6- mm nodule is identified in the right upper lobe. there are no pathologically enlarged mediastinal or hilar lymph nodes identified. 3. sclerotic lesion in the t10 vertebral body consistent with known metastasis. 4. high attenuation lesion in the liver, incompletely evaluated. abdominal usg [**2161-4-16**]: 1. three predominately hypoechoic masses in the liver, one in the right lobe containing heterogeneous echotexture with internal vascularity. this is concerning for metastatic disease and should be further evaluated with mri. 2. diffuse heterogeneous echotexture to the liver, which may be due to fatty infiltration; however, hepatic fibrosis and/or cirrhosis cannot be excluded. brief hospital course: mrs. [**known firstname **] [**known lastname **] is a very nice 39-year-old woman with metastatic nsclc to the bone and brain who recently was taken off her keppra who comes with multiple seizures. (1) seizures: partial seizures were secondarily generalized. this is secondarily caused by her cns metastases of her nsclc with recent decrease in dose of her decadron and stopping her keppra for abnormal lfts. she is currently back on steroids and keppra and seizure free. a alcohol withdrawal seizures cannot be fully rule out, but they are less likely. patient was discharged with follow up with dr. [**last name (stitle) 724**]. she will stay on dexamethasone 4 mg tid and keppra 1 gram [**hospital1 **]. (2) nsclc stage iv: dr. [**first name8 (namepattern2) **] [**name (stitle) 3274**] will follow as outpatient in conjunction with patient's oncologist close to home (per pt and oncologist request). she already completed chemotherapy and 14 whole-brain radiation sessions. (3) high temperature: upon admission t up to 101 f. this is most likely secondary to seizure activity. patient was afebrile for the rest of the hospitalization. (4) uti: patient with abnormal ua with nitrites, leukocytes and bacteria. she was asymptomatic, but in the setting of cns pathology and seizures, there was concern of the risk of an infection and it was thought [**initials (namepattern4) **] [**last name (namepattern4) **]\bar puncture and start treatment was indicated. urine culture could be contaminant with s. aureus. we cannot give quinolones to avoid decreasing seizure threashold. therefore we will started bactrim ds for 3 days. (5) abnormal lfts: patient with hepatocellular pattern abnormalities suggesting hepatocyte damage. this is most likely etiology is hepatic involvement of her nsclc. luq usg shows lesions, suggesting hepatic involvement. but we will follow with dr. [**last name (stitle) 3274**] to evaluate treatment. (6) skin rash: this may be secondary to keppra, but in the setting of recent seizures will monitor for now. antibiotics (vancomycin/cetriaxone in er) etiology is less likely. we will follow and use sarna lotion for now since risk of switching to other medications and having seizures or other adverse reaction outweighs benefits. rash was stable upon discharge. (5) sinus tachycardia: patient seems relaxed and was not in pain. we ruled out pe with cta. pt had sinus tachycardia in multiple ecgs. after 24 hours and hydration hr decreased to 80-90. (6) fen/gi: regular diet. (7) prophylaxis: subcutaneous heparin and bowel regimen. access: piv. code: full code. comm: patient and hcp (husband). medications on admission: dexamethasone 4 mg po four times a day. discharge medications: 1. levetiracetam 500 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 2. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for uti for 2 days. disp:*4 tablet(s)* refills:*0* 3. dexamethasone 4 mg tablet sig: one (1) tablet po twice times a day. disp:*120 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: primary diagnosis: seizure secondary to non-small cell lung cancer metastatic to the brain. secondary diagnsosis: non-small cell lung cancer stage iv discharge condition: stable, seizure free, pain controled, ambulating, and tolerating po. discharge instructions: you were seen at the [**hospital1 18**] for seizures. you recently had your dexamethasone dose decreased and your keppra stopped. you had seizures in the er and responded to ativan. you were re-started on our keppra and your dexamethasone was increased. you had a ct scan that showed no changes from before and no bleeding. you have been seizure free for the last 48 hours. if you have headache, vision abnormalities, abnormal movements, any other seizure activity, headache or anything esle that bothers you please contact dr.[**name (ni) 6767**] office of come to our er. you also had fever upon arrival that were most likely due to your seizure activity. we worked you up for infection and found some abnormalities in your urine concerning for infection. we started you on an antibiotic for that and you will need to complete 2 more days at home. you have abnormal liver function tests, that you already knew, that will need to be followed by dr. [**first name11 (name pattern1) **] [**initial (namepattern1) **] [**last name (namepattern4) 724**]. you will need to follow up with your oncologist, dr. [**first name (stitle) **] t. [**doctor last name 724**] and we made a new appointment with an oncologist at [**hospital1 18**], dr. [**first name8 (namepattern2) **] [**name (stitle) 3274**] (see below). followup instructions: provider: [**first name11 (name pattern1) 640**] [**last name (namepattern4) 4861**], md phone:[**telephone/fax (1) 1844**] date/time:[**2161-4-27**] 10:30 provider: [**first name11 (name pattern1) 640**] [**last name (namepattern4) 4861**], md phone:[**telephone/fax (1) 1844**] date/time:[**2161-6-1**] 11:30 provider: [**name10 (nameis) 706**] mri phone:[**telephone/fax (1) 327**] date/time:[**2161-6-1**] 9:55 dr. [**first name8 (namepattern2) **] [**name (stitle) **] office is scheduling an appointment for next week. they will call you with the appointment. his phone number is: ([**telephone/fax (1) 3280**].",1
111,"admission date: [**2174-3-14**] discharge date: [**2174-3-18**] date of birth: [**2096-8-9**] sex: f service: medicine allergies: aspirin / atorvastatin attending:[**first name3 (lf) 545**] chief complaint: weakness major surgical or invasive procedure: none history of present illness: 77yo woman with history of cad without mi, not on medications, no stent who presents with a chief complaint of generalized weakness. patient reports an ongoing uri for the past two weeks with specific complaints of cough intermittently productive of yellow sputum, congestion and laryngitis. she identifies both her daughter and grandson and [**name2 (ni) **] contacts as they have been experiencing the same symptoms and the daughter notes being diagnosed with ""pneumonia"". these symptoms were gradually resolving, but on friday, [**3-11**], patient noted fevers to 101 without chills or sweats as well as persistent left shoulder pain. she denies any injury to her shoulder, though she does admit to heavy lifting as she was cleaning her attick. her shoulder pain continued until saturday and led her to take tylenol every 6 hours with moderate relief. on [**month/year (2) 1017**], the day of admission, patient reports waking up and feeling profoundly lethargic, unable to walk down the stairs of her home to prepare coffee. she also reports feeling presyncopal without actual syncope. patient denies chest pain, sob, palpitations, abdominal pain, diarrhea, melena, hematochezia, hematemesis, rashes, but does recall noticing that her skin and eyes looked ""beige"" since friday. she also recalls hematuria and urinary frequency without dysuria. given the ongoing symptoms, namely fatigue, patient presented to [**hospital **] hospital where labs revealed a hct of 14 and a smear showed shistocytes. there was concern for hemolysis and need for further work-up so she was transferred to [**hospital1 18**] for further evaluation. in the [**hospital1 18**] ed, repeat hct was 16 with high ldh and t bili. haptoglobin was still pending at the time of admission. though patient was hemodynamically stable, she was admitted to the icu for close monitoring while the work-up for presumed hemolytic anemia continued. past medical history: cad (cath done at osh because of ekg changes revealed ""mild cad"" which was not intervened upon) allergies/adverse reactions: aspirin (epistaxis) lipitor (muscle aches) social history: patient has a former history of tobacco use, up to 1 ppd, but stopped in [**2173-6-23**]. she very infrequently consumes alcohol and denies illicit drug use. she used to do office work for her father's business in her 30s, but has since worked as a homemaker. she has one daugher and one grandson. she lives alone and performs all of her adls. family history: nc physical exam: vitals: t - 97.1, bp - 143/63, hr - 81, rr - 18, o2 - 99% 2 l nc general: awake, alert, nad heent: nc/at; perrla, eomi, + scleral icterus; op clear, nonerythematous, icteric mucous membranes neck: supple, no lad chest/cv: s1, s2 nl, no m/r/g appreciated lungs: ctab abd: soft, nt, nd, + bs rectal: brown, guaiac negative stool ext: no c/c/e neuro: grossly intact skin: no lesions pertinent results: [**2174-3-13**] 11:43pm blood wbc-28.6* rbc-1.95* hgb-6.0* hct-16.7* mcv-86 mch-30.6 mchc-35.8* rdw-17.2* plt ct-683* [**2174-3-13**] 11:43pm blood neuts-86* bands-2 lymphs-3* monos-5 eos-0 baso-0 atyps-4* metas-0 myelos-0 [**2174-3-13**] 11:43pm blood hypochr-3+ anisocy-2+ poiklo-2+ macrocy-2+ microcy-1+ polychr-2+ ovalocy-occasional target-2+ stipple-1+ [**2174-3-13**] 11:43pm blood plt ct-683* [**2174-3-14**] 01:00am blood fibrino-788* d-dimer-[**2085**]* [**2174-3-13**] 11:43pm blood ret aut-7.0* [**2174-3-13**] 11:43pm blood glucose-178* urean-32* creat-0.9 na-134 k-4.9 cl-102 hco3-22 angap-15 [**2174-3-13**] 11:43pm blood alt-31 ast-65* ld(ldh)-2069* alkphos-123* totbili-5.4* [**2174-3-13**] 11:43pm blood lipase-52 [**2174-3-13**] 11:43pm blood hapto-less than [**2174-3-13**] 11:43pm urine color-[**location (un) **] appear-cloudy sp [**last name (un) **]-1.014 [**2174-3-13**] 11:43pm urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-tr [**2174-3-13**] 11:43pm urine rbc-[**5-3**]* wbc-[**5-3**]* bacteri-mod yeast-none epi-[**1-26**] renalep-0-2 [**2174-3-13**] 11:43pm urine castgr-[**1-26**]* casthy-0-2 [**2174-3-13**] 11:43pm urine mucous-mod chest (portable ap) [**2174-3-13**] 11:24 pm findings: single portable upright chest radiograph is reviewed without comparison. cardiomediastinal silhouette is unremarkable allowing for the limitations of portable technique. pulmonary vascularity appears normal. ill- defined opacity projecting over the left lung base most likely represents superimposed breast shadow. a dedicated pa and lateral examination would be helpful in resolving, if this is an area of clinical concern. otherwise, the lungs are clear. there is no pleural effusion or pneumothorax. ct abd w&w/o c [**2174-3-14**] 7:41 pm cta chest w&w/o c&recons, non-; ct abd w&w/o c impression: 1. no pulmonary embolism is detected. 2. lingular atelectasis and mild inflammatory changes in the left upper lobe. 3. 1.3cm right upper lobe nodule is concerning for lung cancer. further evaluation with pet scan is recommended. 4. small focal dissection in the infrarenal aorta likely chronic. brief hospital course: 77yo woman with recent uri admitted with hemolytic anemia (hct 14) due to cold agglutinins. # hemolytic anemia: the patient was found to have autoimmune hemolytic anemia due to cold agglutinins. possible causes include infections such as mycoplasma pneumonia, ebv, cmv, or varicella or lymphoproliferative disorders. mycoplasma, ebv and cmv serologies were negative for recent infection; preliminary results from flow cytometry were not suggestive of lymphoma, but the final results were still pending at time of discharge. she received transfusions of packed red blood cells and her hematocrit improved to 30, which was stable for 2 days prior to her discharge. her hemolysis labs were improving at the time of discharge. she was given follow-up with hematology within one week of discharge. # rul lung mass: patient underwent ct of her chest for work-up of possible pneumonia, and right upper lobe nodule was incidentally found. per hematology, even if this nodule represented lung cancer, a solid lung tumor is not likley to be associated with her cold agglutinin hemolytic anemia. the patient should undergo pet scan and biopsy (likely by ct guided approach given peripheral nature of lesion) in the next several weeks. this was discussed with dr. [**last name (stitle) 29188**], the covering physician for the patient's pcp. [**name10 (nameis) **] patient has follow-up with her pcp in less than one week, and the patient understands that the lung lesion needs to be biopsied. # pneumonia: left lower lung opacity on cxr suggestive of pneumonia. given recent clinical symptoms of cough, the patient was treated with cefpodoxime and azithromycin for possible pneumonia. # infrarenal aortic dissection: a small focal dissection was incidentally noted on ct. she will need outpatient medical management and follow-up imaging, to be coordinated by her pcp. # cad: the patient has h/o cad with wall motion abnormalities on stress echo in [**2169**], but only mild cad on cath in [**2169**] with no significant stenoses. the patient was initially maintained on telemetry but this was discontinued as she was hemodynamically stable, the t wave inversions noted on admission ecg were present on last ecg in [**6-/2170**], and 4 sets of cardiac enzymes were sent during hospitalization and were all negative. she was not started on a daily aspirin given her h/o significant epistaxis while on aspirin and only mild cad. # hyperlipidemia: patient has not been able to adhere to lifestyle modifications to reduce cholesterol since cad diagnosis in [**2169**]. she had muscle aches with lipitor in past, but unclear if had elevated lfts or ck. no changes in medication were made while in hospital, but the patient was advised to ask her pcp for referral to a dietitian. # lle pain: the patient noted pain in her left lower extremity mid-way through hospitalization. the pain was reproducible with straightening of her leg but not tender to palpation, and she had no swelling or erythema. the pain improved with ambulation during the course of the day, and muscular cramping was considered the most likely etiology. physical therapy was consulted, particularly given the patient's dizziness prior to admission and noted no deficits in the patient's mobility. medications on admission: none discharge medications: 1. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 2. azithromycin 500 mg tablet sig: one (1) tablet po once a day for 2 days: please take on saturday and on [**year (4 digits) 1017**] and then stop. disp:*2 tablet(s)* refills:*0* 3. cefpodoxime 200 mg tablet sig: one (1) tablet po twice a day for 2 days: last day to take is [**year (4 digits) 1017**] [**3-20**]. disp:*5 tablet(s)* refills:*0* 4. outpatient lab work please draw patient's hematocrit and have the result called to dr. [**last name (stitle) 29188**] at [**telephone/fax (1) 9146**]. the result should also be faxed to dr. [**last name (stitle) 78856**] at [**telephone/fax (1) 78857**]. please note that the patient's hematocrit on [**3-18**] is 30. discharge disposition: home discharge diagnosis: primary diagnosis: hemolytic anemia due to cold agglutinins secondary diagnoses: pneumonia, mild coronary artery disease, infrarenal aortic dissection, right upper lobe lung nodule discharge condition: afebrile with stable vital signs, feeling well. cough improved. hematocrit stable at 30 for 2 days. discharge instructions: you were admitted with anemia that was found to be due to cold agglutinins, which are antibodies that can cause your blood cells to be chewed up. you received blood transfusions and your blood counts have been stable. you were also treated for a pneumonia. 1. please take all medications as prescribed. the following medications were started during your stay here: - antibiotics (cefpodoxime and azithromycin) for the pneumonia - folate to help you with your anemia 2. please attend all follow-up appointments listed below. 3. please call your doctor or return to the hospital if you develop fevers, yellowing of your skin, fatigue, worsening cough, change in color of your fingers, or any other concerning symptom. 4. we recommend that you wear hats, scarfs, and mittens on cool days and that you avoid going out in the cold weather. please discuss these recommendations with hematology when you see them. 5. please have your blood drawn on [**last name (lf) 1017**], [**3-20**]. the results will be sent to dr. [**last name (stitle) **] and to his covering physician, [**last name (namepattern4) **]. [**last name (stitle) 29188**]. note that your hematocrit before you left the hospital was 30. followup instructions: 1. you have an appointment with your primary care doctor, d. [**last name (stitle) **], on thursday [**3-24**] at 3:15pm. it is important that you discuss with your primary doctor getting a biopsy of the spot on your lung. 2. you have an appointment with hematology: provider: [**first name11 (name pattern1) 2295**] [**last name (namepattern4) 11222**], md phone:[**telephone/fax (1) 22**] date/time:[**2174-3-23**] 4:00pm on the [**location (un) **] of the [**hospital ward name 23**] building at the corner of [**location (un) **] and [**hospital1 1426**] avenues. completed by:[**2174-3-23**]",1
112,"admission date: [**2166-11-29**] discharge date: [**2166-12-3**] date of birth: [**2099-5-14**] sex: m service: neurology allergies: penicillins / sulfa (sulfonamide antibiotics) / doxycycline attending:[**first name3 (lf) 618**] chief complaint: weakness, fall major surgical or invasive procedure: none history of present illness: hpi: 67 yo rh man with pmh of htn, prostate ca was transfered from osh for evaluation of ich. this am, he tried to get up from bed around 11 am,. as soon as he got up from bed and tried to walk, he fell down. he felt that both his legs are weak, but left was much more weak than right side. he felt weakness in lue as well. he was on the floor and was crawling around the house. he was awake the entire period , alert and knew that he had weakness and heavy feeling on the left side, both upper and lower extremities. at around 12 noon, he crwaled over, somehoe managed to get hold of his medicines and he took a tablet of aspirin and atenonol. he thinks that weakness and heavy feeling was same all over this period. it did not increase or fluctuate and was maximum at the onset. he didnt call 911 and thought that it will go away. when his wife returned from work around 6 pm, she noted that he is lying in the floor.he was awake , able to answer all questions. he was taken to osh for evaluation. at [**hospital **] hospital, his blood pressure was very high 190/110, he was noted be having ""sensory deficits on left side and some weakness on left side"" basic lab work was done, wbc 10, hb 15.4, plt 224, trop less than 0.03, inr 1, cpk 568. ct head showed a large iph in the right basal ganglia with intraventricular spread and shift. he denies any vision changes, sensory changes, clumsiness. he does endorse a mild headache for the last few hours. past medical history: htn, prostate ca. thyroid cyst appendectomy multiple orthopedic procedures prostate surgery social history: retired, most recently worked as a printer.exd smoker left 34 years ago, 10 pack years. 1 glass of wine per week family history: prostate ca in father, cad in father physical exam: o: t: 98.0 bp: 191/120 hr: 80 r 14 o2sats 100 gen: wd/wn, comfortable, nad. heent: pupils: perrl [**2-20**] neck: supple. lungs: cta bilaterally. cardiac: rrr. s1/s2. abd: soft, nt, bs+ extrem: warm and well-perfused. neuro: mental status: awake and alert, cooperative with exam, normal affect. orientation: oriented to person, place, and date. attentive with months of the year backwards language: speech fluent with good comprehension and repetition. he is able to read all the sentences on the stroke card. he is able to name all the obejcts over the stroke card and describe the picture. no dysarthria or paraphasic errors. no apraxia, shows how to brush teeth. cranial nerves: i: not tested ii: pupils equally round and reactive to light, 4 to 2 mm bilaterally. visual fields full but with occasional left field neglect sometimes he is able to tell the obejcts in both fields but sometimes he misses on the objects on the left side. iii, iv, vi: extraocular movements intact bilaterally without nystagmus. v, vii: facial strength and sensation intact and symmetric. viii: hearing intact to voice. ix, x: palatal elevation symmetrical. [**doctor first name 81**]: sternocleidomastoid and trapezius normal bilaterally. xii: tongue midline without fasciculations. motor: normal bulk and tone bilaterally. no abnormal movements, tremors. significant promator drift on left. delt bic tri wre ffl fe io ip quad ham ta [**first name9 (namepattern2) 2339**] [**last name (un) 938**] edb l 4- 5 4- 4- 5 3 4 4 5 4 5 5 4 5 r 5 5 5 5 5 5 5 5 5 5 5 5 5 5 sensation: intact to light touch, pain , vibration and position. throughout but with significant left hemibody sensory neglect to double simultaneous stimulation. reflexes: b t br pa ac right 1 1 1 2 2 left 1 1 1 2 2 toes up bilaterally coordination: intact throughout right but ataxic left on fnf and heel shin testing. rapid tapping clumsy on left side as well. pertinent results: [**2166-11-28**] 11:48pm pt-12.6 ptt-24.8 inr(pt)-1.1 [**2166-11-28**] 11:48pm plt count-191 [**2166-11-28**] 11:48pm wbc-9.0 rbc-5.55 hgb-15.0 hct-45.3 mcv-82 mch-27.0 mchc-33.1 rdw-13.1 [**2166-11-28**] 11:48pm ck-mb-11* mb indx-2.1 [**2166-11-28**] 11:48pm ctropnt-<0.01 [**2166-11-28**] 11:48pm ck(cpk)-512* [**2166-11-28**] 11:48pm glucose-122* urea n-15 creat-0.9 sodium-138 potassium-4.0 chloride-100 total co2-24 anion gap-18 [**2166-11-29**] 10:00am urine rbc-0-2 wbc-[**1-23**] bacteria-occ yeast-none epi-0-2 [**2166-11-29**] 10:00am urine blood-mod nitrite-neg protein-75 glucose-neg ketone-15 bilirubin-sm urobilngn-neg ph-6.5 leuk-sm [**2166-11-29**] 10:00am urine bnzodzpn-neg barbitrt-neg opiates-pos cocaine-neg amphetmn-neg mthdone-neg [**2166-11-29**] 10:36am calcium-8.9 phosphate-2.9 magnesium-1.9 [**2166-11-29**] 10:36am ck-mb-8 ctropnt-<0.01 [**2166-11-29**] 10:36am ck(cpk)-469* [**2166-11-29**] 10:36am glucose-134* urea n-20 creat-1.2 sodium-139 potassium-3.7 chloride-102 total co2-25 anion gap-16 [**2166-11-29**] 06:24pm ck-mb-8 [**2166-11-29**] 06:24pm ck(cpk)-450* ct head [**2166-11-29**] comparison: outside hospital head ct performed at [**hospital **] hospital at 8:58 p.m. on [**2166-11-28**]. findings: there is a hyperdense acute 5.3 x 2.3 cm hemorrhage centered in the region of the right thalamus extending into the caudate. there is hemorrhage in the the third ventricle (2:15) and occipital horns of both lateral ventricles and denser appearanc eof the choroid plexux in the body of the right lateral ventrcile.(2:14). there is diffuse subarachnoid hemorrhage, in the region of the right sylvian fissure (2:19) and along the posterior parietal sulci on both sdies, more prominent from prior (2:19). the frontal [**doctor last name 534**] of the right lateral ventricle is compressed by the mass effect from this hemorrhage. there is very minimal shift of midline structures to left. the size and configuration of the ventricles is stable compared to the earlier examination, with slight prominence of the temporal horns of the lateral ventricles. there are no new foci of hemorrhage. [**doctor last name **]-white matter differentiation appears well preserved without evidence for acute infarct. there is expansion of the left frontal bone with heterogeneous appearance, including lucent areas within- (series 105b/im 28-33) the differential diagnosis includes fibrous dysplasia, hemangioma, etc and further evaluation with mr can be helpful to further characterize. a samllr etention cyst is noted in the left maxillary sinus. impression: 1. multicompartmental acute intracranial hemorrhage as above with involvement of the right thalamus, caudate and 3rd and lateral ventricles and sah as above. mass effect on the right lateral ventricle, unchanged. associated vascular cause cannot be excluded based on this exam, though this is likely to be seen with htn- correlate with hisotry and consider further work up for the same. 2. subarachnoid hemorrhage and intraventricular hemorrhage, more apparent than on the prior examination. 3. expansion of the left frontal bone with heterogeneous appearance, as described above- ddx includes fibrous dysplasia, hemangioma less likely, etc. further evaluation with mr can be helpful to assess nature and extent, if there is no contra-indication. cxr [**2166-11-29**] impression: mild cardiomegaly, but no consolidations. elbow x-ray [**2166-11-29**] findings: an iv catheter is seen in the antecubital fossa with a kink in the iv line. a bony spur seen at the olecranon. other than mild degenerative changes, the elbow appears normal. ct head [**2166-11-30**] impression: 1. parenchymal hemorrhage centered in the right basal ganglia, corona radiata and thalamus, extending into the ventricles and, to a lesser extent, subarachnoid spaces. the overall appearance suggests primary hypertensive hemorrhage. 2. overall, the total volume of hemorrhage appears similar to the comparison study, and there is no evidence of interval hemorrhage or definite development of hydrocephalus. cxr [**2166-12-2**] a single bedside radiograph of the chest excludes the lung apices from the field of view. within that constraint the lungs appear unchanged, with no focal consolidation, pleural effusion or pneumothorax. cardiac, mediastinal and hilar contours are also unchanged. the study and the report were reviewed by the staff radiologist. brief hospital course: mr. [**known lastname 84196**] is a 67 yo rhm with htn who presented with acute onset weakness and heaviness over left side. exam at the time of admission showed left hemiparesis (arm more than leg), left hemisensory neglect more prominent to tactile stimuli than visual fields, and bl upgoing toes. the ct scan shows large r bg bleed with iv extension. the most likely etiology is hypertension, given his uncontrolled blood pressure and typical location of bleed. he had been seen by neurosurgery who have suggested no acute intervention. he was initially admitted to the neurology icu and started on a nicardipine drip for blood pressure control. a repeat ct head showed a stable size of his hemorrhage and he was titrated off the nicardipine drip and transferred to the floor. initially he had some difficulties with blood pressure control and his home atenolol was increased to 100 mg [**hospital1 **] with good response. his other home medications including his [**last name (un) **] and inspira were continued. his outpatient cardiologist, dr. [**last name (stitle) **] was contact[**name (ni) **] regarding his medical regimen and it was determined that he has had a number of intolerance/adverse reaction to multiple other antihypertensives including ace-inhibitors and calcium channel blockers. dr. [**last name (stitle) **] commented that he was planning to start mr. [**known lastname 84196**] on tektura 150 mg daily. this may be considered if his blood pressure requires additional treatment. id- on [**2166-12-1**] the patient spiked a temperature of 102. he was pancultured which have been unrevealing. final blood cultures are still pending at the time of discharge. msk- patient did have some occasional lower back pain during the hospital course. a plain film x-ray did not reveal any identifiable cause. it was thought this may have been musculoskeletal and has been controlled with tylenol and occasional oxycodone for breakthrough pain medications on admission: tenormin 37.5, 12.5 am and 25 pm avapro 300mg daily, inspira 100mg daily, centrum magnesium ca / vit d asa 325 on the morning of presentation discharge medications: 1. eplerenone 50 mg tablet sig: two (2) tablet po qpm (once a day (in the evening)). 2. magnesium oxide 140 mg capsule sig: two (2) capsule po daily (daily). 3. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po q 12h (every 12 hours). 4. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 5. losartan 50 mg tablet sig: two (2) tablet po daily (daily). 6. oxycodone 5 mg capsule sig: one (1) capsule po q4h (every 4 hours) as needed for pain. 7. atenolol 50 mg tablet sig: two (2) tablet po bid (2 times a day). 8. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain/fever. 9. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). discharge disposition: extended care facility: [**hospital3 1107**] [**hospital **] [**hospital 1108**] rehab unit at [**hospital6 1109**] - [**location (un) 1110**] discharge diagnosis: right basal ganglia hemorrhage discharge condition: ms; a&ox3, speech fluent. naming, repetition, and comprehension intact. cn; mild l neglect on visual fields. eomi, l facial droop motor; 4/5 strength lue, lle limited by back pain but appears at least [**2-23**]. [**3-25**] on rue, rle sensory; extinction to dss on left discharge instructions: you were admitted after an episode of weakness. you were found to have a large bleed in a part of your brain called the basal ganglia which was likely caused by high blood pressure. your bleed has been stable on repeat imaging studies and you will be transferred to a rehabilitation facility for further care. followup instructions: appointment with pcp, [**last name (namepattern4) **]. [**first name (stitle) **] [**name (stitle) 48633**], on tuesday [**2166-12-16**] at 2:30pm. the office is located at [**hospital1 84197**], [**location (un) 47**] [**numeric identifier 7398**]. please call dr.[**name (ni) 84198**] office at [**telephone/fax (1) 35142**] if you need to reschedule this appointment. appointment with neurology stroke attending, dr. [**last name (stitle) **], on tuesday [**2167-1-6**], at 1:30pm. the office is located in the [**hospital ward name 23**] building [**location (un) **] at [**hospital1 18**]. please call dr. [**name (ni) 59895**] office at [**telephone/fax (1) 2574**] if you need to reschedule this appointment. when you are discharged from rehab, please call your cardiologist, dr. [**last name (stitle) **] ([**telephone/fax (1) 5068**]) for a follow-up appointment. [**name6 (md) **] [**name8 (md) **] md, [**md number(3) 632**]",1
113,"admission date: [**2142-10-4**] discharge date: [**2142-10-14**] service: orthopaedics allergies: patient recorded as having no known allergies to drugs attending:[**first name3 (lf) 64**] chief complaint: r knee replacement c/b postop hypotension major surgical or invasive procedure: or [**10-4**]: r tka. or [**10-8**]: l tka. history of present illness: ortho hpi: 86m w/ severe b/l oa, admitted to ortho for sequential bilateral tka. pt was admitted to icu for hypotension and tachycardia x 3 which subsequently resolved and was transferred to the floor. pt ultimately underwent bilateral tka w/o complications. icu hpi: 86 y/o m with pmhx of arthritis, bph & osteoporosis s/p elective right total knee replacement c/b post-op hypotension. pt was not intubated, he received spinal anesthesia with superifical femoral block and ebl was 160cc. after one uneventful pain-free hour in pacu, patient began ""rigoring"", sbp climbed into 200s and hr into 150s. pt denied cp/sob. after receiving labetalol 5mg iv with metoprolol 2mg iv, sbp dropped to 160. an ekg revealed sinus tachycardia with hr 103, and pacs. after a second dose of metoprolol 2.5mg iv, the pt's sbps dropped into 70s and the pt became lethargic and ashen [**doctor last name 352**]. sbp recovered to 100s after a neosynephrine bolus (100mcg); and the sbp subsequently recovered to the 170s. an a-line was placed. on arrival to icu, the pt's sbp was measured to be elevated at 170/70 by the arterial line. the pt denied sob and cp, but complained of nausea that he attributed to not eating for 24hrs. during an attempted piv placement, the sbp suddenly dropped to 70/40s, hr remained in the 80s (t stable at 98.7, and bs 167). pt complained of lightheadedness, diaphoresis & nausea. after an ivf bolus, the sbp recovered to 140s within minutes and symptoms resolved. . ros: pt denied any recent fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, cough, urinary frequency, urgency, dysuria, lightheadedness, syncopal episodes. past medical history: osteoporosis anemia (family h/o g6pd deficiency) bph osteoarthritis cataracts s/p bilateral inguinal hernia repair social history: social history: pt lives with daughter who is an internist and denies any smoking, etoh abuse living situation: he lives with his wife in a single family home in [**country **]. he has one daughter who lives in [**country **]. his other daughter and son live here in [**name (ni) 86**]. he is currently staying with his daughter since [**name (ni) 205**] for surgery. background: the patient is retired from working as an engineer. habits: no etoh, substance use, quit smoking in [**2104**], 30 pack-years nutrition: 3 meals/day, no weight loss family history: family medical history: non-contributory physical exam: vitals: t: 96 bp: 179/77 hr: 84 rr: 18 o2sat: 100% on 2l gen: wdwn, pale but in no acute distress heent: eomi, perrl, sclera anicteric, no epistaxis or rhinorrhea, mucous membranes dry cor: rrr, no appreciable m/g/r, normal s1 s2 pulm: lungs ctab, no w/r/r abd: soft, nt, nd, +bs, no hsm, no masses ext: no c/c/e +dp/pt bilaterally, moving distal extremities well right knee drain with serosanguinous fluid, brace in place neuro: alert, oriented to hospital & month. 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. ms exam: wound c/d/i; no erythema; no ssd; [**last name (un) 938**]/ta/gs intact. pertinent results: [**2142-10-12**] 05:52am blood wbc-12.3* rbc-4.01* hgb-9.0* hct-28.0* mcv-70* mch-22.4* mchc-32.1 rdw-19.1* plt ct-425 [**2142-10-11**] 06:50am blood wbc-11.5* rbc-4.41* hgb-10.0* hct-30.7* mcv-70* mch-22.7* mchc-32.6 rdw-18.9* plt ct-358 [**2142-10-10**] 07:10am blood wbc-8.4 rbc-4.30* hgb-10.1* hct-29.8* mcv-69* mch-23.5* mchc-33.9 rdw-18.6* plt ct-297 [**2142-10-9**] 08:14pm blood wbc-9.1 rbc-4.42* hgb-10.4* hct-30.6* mcv-69* mch-23.5* mchc-33.9 rdw-18.5* plt ct-297 [**2142-10-5**] 12:21am blood neuts-84.2* lymphs-10.4* monos-5.1 eos-0.2 baso-0 [**2142-10-4**] 08:54pm blood neuts-70.2* lymphs-24.3 monos-4.5 eos-0.8 baso-0.2 [**2142-10-12**] 05:52am blood plt ct-425 [**2142-10-11**] 06:50am blood plt ct-358 [**2142-10-10**] 07:10am blood plt ct-297 [**2142-10-9**] 08:14pm blood plt ct-297 [**2142-10-9**] 02:00am blood plt ct-252 [**2142-10-10**] 07:10am blood glucose-108* urean-14 creat-0.9 na-133 k-4.5 cl-99 hco3-26 angap-13 [**2142-10-9**] 08:14pm blood glucose-154* urean-15 creat-0.9 na-138 k-4.2 cl-103 hco3-22 angap-17 [**2142-10-9**] 02:00am blood glucose-96 urean-15 creat-0.8 na-137 k-3.7 cl-104 hco3-24 angap-13 [**2142-10-5**] 03:49pm blood ck(cpk)-109 [**2142-10-5**] 12:21am blood ck(cpk)-69 [**2142-10-4**] 08:54pm blood ck(cpk)-68 [**2142-10-5**] 03:49pm blood ck-mb-3 ctropnt-<0.01 [**2142-10-5**] 12:21am blood ck-mb-3 ctropnt-<0.01 [**2142-10-4**] 08:54pm blood ck-mb-3 ctropnt-<0.01 [**2142-10-5**] 12:21am blood calcium-8.7 phos-4.0 mg-2.3 [**2142-10-4**] 08:54pm blood calcium-7.2* phos-3.4 mg-1.3* brief hospital course: icu course: assessment & plan: 86 y/o m with pmhx of osteoarthritis and bph presentd for elective tkr today and has developped transient recurrent episodes of hypotension with diaphoresis/nausea that resolve with small ivf bolus. . # hypotension: [**3-17**] spinal anesthesia +/- autonomic dysfunction given recovery with ivfs and discontinuation of anesthetic. no evidence of wound infection, sepsis, inferior mi, hypovolemia 2/2 blood loss given minimal ebl, or adverse reaction to beta blockers. empiric vancomycin and ceftriaxone for possible uti were initiated. all antihypertnesives were held, and sbp recovered. a rule-out mi with 3x cardiac enzymes/ecgs was negative. - monitor sbps & bolus ivf prn - f/u blood/urine cultures - trend wbc count fever curve - npo for now . # s/p tkr: pain was well controlled by femoral block. lovenox was held post op until pod1. - lovenox till am per ortho recs - f/u ortho recs - monitor drainage and distal pulses . # fen: npo for now except meds/ice chips - monitor lytes & replete prn . # access: 2 x pivs . # ppx: pneumoboots, ppi, bowel regimen - per ortho, lovenox to start in am . # code: full confirmed with hcp . # dispo: ortho . # comm: with patient & daughter/hcp floor transfer once patient was transferred to the floor after 24hrs of observation, pt had no similar episodes of hypotension. pt remained slightly tachycardic at 100-110. he did have an episode of tachycardia to 140-150s without any stimulus, but no reasons were found. cardiology was consulted who recommended lopressor 100 [**hospital1 **]. echo and ekgs were normal. troponin were normal. pt was ultimately cleared for his r tka ([**2142-10-4**]) on pod4 from ltka ([**2142-10-8**]). pt was taken to the operating room by dr. [**last name (stitle) **] where the patient underwent uncomplicated r tka. the procedure was well tolerated and there were no complications. please see the separately dictated operative report for details regarding the surgery. the patient was subsequently transferred to the post-anesthesia care unit in stable condition and transferred to the floor later that day. overnight, the patient was placed on a pca for pain control. iv antibiotics were continued for 24 hours postoperatively as per routine. lovenox was started the morning of postop day 1 for dvt prophylaxis. the patient was placed in a cpm machine with range of motion set at 0-45 degrees of flexion up to 90 degrees as tolerated for both knees. the drain was removed without incident. the patient was weaned off of the pca onto oral pain medications. the foley catheter was removed without incident. the surgical dressing was also removed, and the surgical incision was found to be clean, dry, and intact without erythema nor purulent drainage. during the hospital course the patient was seen daily by physical therapy. labs were checked both post-operatively and throughout the hospital course and repleted accordingly. the patient was tolerating regular diet and otherwise feeling well. prior to discharge the patient was afebrile with stable vital signs. hematocrit was stable and pain was adequately controlled on a po regimen. the operative extremity was neurovascularly intact and the wound was benign. the patient was discharged to rehabilitation in a stable condition. cardiology a/p: lopressor 100 [**hospital1 **]; tachycardia likely d/t atrial tach; can f/u with outpt; echo nl; unremarkable ekg; trop neg in icu. geriatrics a/p: some crackles in lll; cxr largely neg w/ some haziness of lll; no fever; no respiratory distress -> empiric augmentin 500 x 10days for pna coverage. medications on admission: fosamax 70 mg qweek flomax 0.4 mg daily (inconsistent) calcium 500 mg daily, multivitamin daily tylenol 500 mg p.r.n. discharge medications: 1. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 2. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po q 8h (every 8 hours). 3. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). 4. multivitamin tablet sig: one (1) tablet po daily (daily). 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q12h (every 12 hours) as needed. 7. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours). 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 9. lovenox 40 mg/0.4 ml syringe sig: one (1) subcutaneous once a day for 3 weeks: after lovenox for 3 wks, start aspirin. 10. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 11. tamsulosin 0.4 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po daily (daily). 12. amoxicillin-pot clavulanate 500-125 mg tablet sig: one (1) tablet po q8h (every 8 hours) for 10 days. 13. oxycodone 5 mg tablet sig: three (3) tablet po q4h (every 4 hours) as needed for pain. 14. lopressor 100 mg tablet sig: one (1) tablet po twice a day. discharge disposition: extended care facility: [**hospital6 85**] - [**location (un) 86**] discharge diagnosis: bilateral tka discharge condition: stable discharge instructions: should experience: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers >101.5, shaking chills, redness or drainage at the incision site, chest pain, shortness of breath or any other concerns. 2. please follow up with your pcp regarding this admission and any new medications and refills. 3. resume your home medications unless otherwise instructed. 4. you have been given medications for your pain control. please do not operate heavy machinery or drink alcohol when taking these medications. as your pain improves, please decrease the amount of pain medication. this medication can cause constipation, so you should drink plenty of water daily and take a stool softener as needed to prevent this side effect. 5. you may not drive a car until cleared to do so by your surgeon or your primary physician. 6. please keep your wounds clean. you can get the wound wet or take a shower starting 5 days after surgery, but no baths or swimming for at least 4 weeks. no dressing is needed if wound continued to be non-draining. any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment, by your pcp or at rehab. 7. please call your surgeons/doctors office to [**name5 (ptitle) **] or confirm your follow-up appointment. anticoagulation: please take lovenox injections (40mg) once a day x 3 weeks and then take aspirin 325 mg twice a day x 3 weeks. [**month (only) 116**] discontinue all blood thinners 6 weeks post-operatively. please call [**first name9 (namepattern2) 22369**] [**doctor last name **] at [**telephone/fax (1) 22370**] with any questions. wound care: keep your incision clean and dry. okay to shower after pod#5 but do not tub-bath or submerge your incision. please place a dry sterile dressing to the wound each day if there is drainage, leave it open to air. check wound regularly for signs of infection such as redness or thick yellow drainage. staples will be removed by vna in 2 weeks. if you are going to rehab, then rehab can remove staples at 2 weeks. activity: weight bearing as tolerated bilaterally; rle can be a routine tka pathway, without any strict precautions; lle must have [**doctor last name 6587**] brace w/ 5degrees of valgus stress to protect lateral collateral ligaments, especially when walking; pt can loose the [**doctor last name 6587**] when in bed for comfort. vna (after home): home pt/ot, dressing changes as instructed, and wound checks, staple removal in 2 weeks after surgery. physical therapy: weight bearing as tolerated bilaterally; rle can be a routine tka pathway, without any strict precautions; lle must have [**doctor last name 6587**] brace w/ 5degrees of valgus stress to protect lateral collateral ligaments, especially when walking; pt can loosen the [**doctor last name 6587**] when in bed for comfort. treatments frequency: should experience: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers >101.5, shaking chills, redness or drainage at the incision site, chest pain, shortness of breath or any other concerns. 2. please follow up with your pcp regarding this admission and any new medications and refills. 3. resume your home medications unless otherwise instructed. 4. you have been given medications for your pain control. please do not operate heavy machinery or drink alcohol when taking these medications. as your pain improves, please decrease the amount of pain medication. this medication can cause constipation, so you should drink plenty of water daily and take a stool softener as needed to prevent this side effect. 5. you may not drive a car until cleared to do so by your surgeon or your primary physician. 6. please keep your wounds clean. you can get the wound wet or take a shower starting 5 days after surgery, but no baths or swimming for at least 4 weeks. no dressing is needed if wound continued to be non-draining. any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment, by your pcp or at rehab. 7. please call your surgeons/doctors office to [**name5 (ptitle) **] or confirm your follow-up appointment. anticoagulation: please take lovenox injections (40mg) once a day x 3 weeks and then take aspirin 325 mg twice a day x 3 weeks. [**month (only) 116**] discontinue all blood thinners 6 weeks post-operatively. please call [**first name9 (namepattern2) 22369**] [**doctor last name **] at [**telephone/fax (1) 22370**] with any questions. wound care: keep your incision clean and dry. okay to shower after pod#5 but do not tub-bath or submerge your incision. please place a dry sterile dressing to the wound each day if there is drainage, leave it open to air. check wound regularly for signs of infection such as redness or thick yellow drainage. staples will be removed by vna in 2 weeks. if you are going to rehab, then rehab can remove staples at 2 weeks. activity: weight bearing as tolerated bilaterally; rle can be a routine tka pathway, without any strict precautions; lle must have [**doctor last name 6587**] brace w/ 5degrees of valgus stress to protect lateral collateral ligaments, especially when walking; pt can loose the [**doctor last name 6587**] when in bed for comfort. vna (after home): home pt/ot, dressing changes as instructed, and wound checks, staple removal in 2 weeks after surgery. followup instructions: provider: [**first name8 (namepattern2) 4599**] [**last name (namepattern1) 9856**], [**md number(3) 3261**]:[**telephone/fax (1) 1228**] date/time:[**2142-11-9**] 10:40 cardiology: [**first name8 (namepattern2) **] [**name8 (md) **] md; [**hospital1 1170**] [**location (un) 830**], e/rw-453 [**location (un) 86**], [**numeric identifier 718**] phone: [**telephone/fax (1) 62**]",1
114,"admission date: [**2153-12-18**] discharge date: [**2153-12-20**] date of birth: [**2085-1-22**] sex: m service: medicine allergies: aspirin attending:[**first name3 (lf) 4765**] chief complaint: chest pain, aspirin desensitization major surgical or invasive procedure: cardiac catherization history of present illness: mr. [**known lastname 7749**] is a 68 yo m with history of asthma, hypertension, hyperlipidemia and as who has had 3-4 days of crescendo angina. the patient reports that starting on friday afternoon he began to have substernal crushing chest pain/tightness. this pain was persistent and improved with rest, but persisted for the duration of the day. he did not have shortness of breath, dizziness or lightheadedness with this episode. the pain recurred several more times over the weekend, usually resolving with rest. the pains required him to stop the participitating activities (working, dancing, snowshoveling). after chest tightness on monday, the patient called his pcp. [**name10 (nameis) **] recommended going to the er if the pain persisted, but if not, then the patient was to come to the pcp's office in am. the patient reported to the pcp's office on tuesday am. he was found to have st depressions and mild troponin elevation. thus the patient was sent directly to the ed (instead of the scheduled stress test). the patient was given plavix 600 mg, atorvastatin 80 mg, metoprolol 2.5 mg x2 iv and started on heparin gtt with bolus. the patient was then transferred to [**hospital1 18**] for aspirin desentization. . on arrival the patient has no chest pain or dyspnea. he reports no current symptoms including no chest pain, no shortness of breath, no dizziness. he is hungry. . on review of systems, he has intermittent cough and occasional dyspnea on exertion x last 5 months. also patient has been having exertional left leg pain over the last few months. he denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. s/he denies recent fevers, chills or rigors. all of the other review of systems were negative. . cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . initial vitals at the osh were not recorded, but bps by ems were 164/88, hr 74, rr 16, 02 98%. past medical history: htn asthma hyperlipidemia rhinitis nasal polyps mild to moderate aortic stenosis single kidney . social history: tobacco history: no history of tobacco, alcohol family history: brother with aaa at age 70, no scd or cad in family. father with lung disease physical exam: general appearance: well appearing height: 74 inch, 188 cm weight: 86 kg eyes: (conjunctiva and lids: wnl) ears, nose, mouth and throat: (oral mucosa: wnl), (teeth, gums and palette: wnl) neck: (jugular veins: jvp, 8), (thyroid: wnl) back / musculoskeletal: (chest wall structure: wnl) respiratory: (effort: wnl), (auscultation: wnl) cardiac: (rhythm: regular), (palpation / pmi: wnl), (auscultation: s1: wnl), (murmur / rub: present), (auscultation details: systolic murmur heard throughout precordium, loudest at rusb, crescendo-decrescendo, no delayed pulses) abdominal / gastrointestinal: (bowel sounds: wnl), (bruits: no), (pulsatile mass: no), (hepatosplenomegaly: no) genitourinary: (wnl) femoral artery: (right femoral artery: 2+, no bruit), (left femoral artery: 2+, no bruit) extremities / musculoskeletal: (digits and nails: wnl), (dorsalis pedis artery: right: 2+, left: 2+), (posterior tibial artery: right: 1+, left: 1+), (edema: right: 0, left: 0), (extremity details: warm) skin: ( wnl) pertinent results: admission labs: [**2153-12-18**] 05:12pm glucose-89 urea n-19 creat-0.9 sodium-142 potassium-3.8 chloride-105 total co2-28 anion gap-13 [**2153-12-18**] 05:12pm wbc-10.8 rbc-4.71 hgb-14.1 hct-39.7* mcv-84 mch-30.0 mchc-35.6* rdw-13.0 cardiac enzymes: [**2153-12-18**] 05:12pm blood ck-mb-notdone ctropnt-0.15* [**2153-12-19**] 12:46am blood ck-mb-notdone ctropnt-0.13* [**2153-12-19**] 04:26pm blood ck-mb-notdone ctropnt-0.15* [**2153-12-19**] 12:46am blood ck(cpk)-74 [**2153-12-19**] 04:26pm blood ck(cpk)-72 admission ekg: sinus rhythm. left ventricular hypertrophy with st-t wave abnormalities the st-t wave changes could be due in part to left ventricular hypertrophy but are nonspecific and clinical correlation is suggested no previous tracing available for comparison brief hospital course: 68 yo m with unstable angina no cp free for >12 hours who presents as transfer for aspirin desentization prior to cardiac catherization. . acs: the patient presented with chest pain consistent with unstable angina, mild troponin elevation and ecg changes make nstemi more likely. given st changes and mild troponin elevation, the likely cause of the chest pain was cad. heparin gtt, plavix, and high-dose atorvastatin were started. the patient was desensitized to aspirin as below. he was taken to the cath lab. the large dominant lcx had mild non-obstructive disease proximally. the small non-dominant rca had a 90% proximal stenosis. two bare metal stents were placed, with good result. he will continue full dose asa and plavix x 1 month and low dose asa 81 mg thereafter. . aortic stenosis/sclerosis: by history it was unclear whether he had aortic stenosis vs aortic sclerosis. on catheterization there was no transaortic pressure gradient. despite this, valve area on echo was 1.0-1.2 cm2. . aspirin desentization: patient reported an asthmatic reaction to aspirin. aspirin desensitization was undertaken with premedication with singulair and prednisone. the patient subsequently tolerated 325 mg aspirin daily without evidence of bronchospasm or other adverse reaction . hypertension: the patient was initially hypertensive and was treated with low-dose nitro gtt. this was transitioned to metoprolol after asa desensitization was complete. patient continued to be hypertensive with sbp ~200. an ace inhibitor was added, and sbp fell to 140-150. further optimization of bp was deferred to pcp. . hyperlipidemia: lipids were well controlled on labs at osh. high-dose atorvastatin was started for nstemi, to continue indefinitely. medications on admission: atenolol 100 mg daily simvastatin 20 mg daily advair 250/50 [**hospital1 **] (patient taking prn) flonase prn (not taking) amoxicillin prn dental procedure proair (prescribed, not taking) discharge medications: 1. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation [**hospital1 **] (2 times a day). disp:*60 disk with device(s)* refills:*2* 4. atenolol 100 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 5. lisinopril 5 mg tablet sig: three (3) tablet po once a day. disp:*90 tablet(s)* refills:*2* 6. aspirin 325 mg tablet sig: one (1) tablet po daily (daily): you must take this medication every day. please go directly to the er if you have any allergic reaction to this including swelling, rash or wheezing. disp:*30 tablet(s)* refills:*2* 7. albuterol 90 mcg/actuation aerosol sig: one (1) inhalation every six (6) hours as needed for shortness of breath or wheezing. disp:*1 1* refills:*0* discharge disposition: home discharge diagnosis: aspirin allergy non-st elevation mi secondary: hypertension discharge condition: improved, no chest pain discharge instructions: you were admitted with a heart attack and were desensitized from aspirin. you also had a stent placed in one of your coronary arteries. thus you are on new medications for your coronary artery disease. your new medications include: aspirin, plavix, lisinopril and lipitor 80 mg. you are not taking simvastatin for now. you must take plavix for at least one month, but do not stop taking it until speaking with a cardiologist. additionally you should never go more than one day without aspirin as you will have to be desensitized from aspirin if you miss more than one to two days. please return to the er or call 911 if you have any chest pain, shortness of breath, passing out, light headedness. additionally any nausea, vomiting, fever or chills, please call your doctor or 911. followup instructions: you should see dr. [**last name (stitle) **] on [**12-26**] at 11 am. theh phone number is [**telephone/fax (1) 4475**] ([**first name8 (namepattern2) 81568**] [**hospital1 **], ma). if you are unable to make the appointment with dr. [**last name (stitle) **], you should see dr. [**last name (stitle) **] in her clinic in the next 1-2 weeks. you can call and make that appointment at [**telephone/fax (1) 62**]. you should also see dr. [**first name (stitle) 1356**] in [**1-8**] weeks after seeing dr. [**last name (stitle) 39288**]. completed by:[**2153-12-20**]",0
115,"admission date: [**2195-4-19**] discharge date: [**2195-4-25**] service: medicine allergies: sulfasalazine / penicillins attending:[**first name3 (lf) 358**] chief complaint: nausea, abdominal pain major surgical or invasive procedure: [**first name3 (lf) **] [**4-19**] with sphincterotomy and stent placement [**month/day (4) **] [**4-21**] with epinephrine injection and gold probe at sphincterotomy stie history of present illness: on the morning of [**4-18**], ms. [**known lastname 83220**] was nauseous and unable to ambulate. she was also lethargic, per her daughter. she evidently complained of sharp upper abdominal pain when arriving to the [**hospital1 1562**] ed per their notes, and she also complained of some rectal pain. (her daughter, however, notes that she was primarily complaining of nausea.) evaluation at the [**hospital 1562**] hospital included a ct abdomen/pelvis which showed likely dilatation of the common bile duct and gallstones in the gallbladder. she was eventually transferred to [**hospital1 18**] for evaluation for [**hospital1 **]. . per daughter: the patient had been recovering from ""broken legs."" daughter reviews past history: about 15 years ago she had bilateral knee replacements at the [**hospital1 112**]; was fine until the end of [**month (only) 404**], her bp went up so high that the oncologist would not give her procrit. once she took a new pill from the cardiologist, she said she felt very dizzy. the next day she was supposed to see the cardiologist, fell on her knees. passed out in the chair when sat up. operated on left knee at [**hospital1 112**]; the prosthesis was pushed up into the femur; the other leg was broken but not as bad as the left knee. since then living at daughter??????s house. was doing well at rehab but couldn??????t live by herself yet. vna rns see her twice a week for pt/ot. . last couple of days has had very low blood pressure 90/50; eating very little and was very lethargic, was complaining a lot of not getting better and feeling depressed. did have a visit from a friend and was very cheerful and energetic. went to bed; but that next morning [**4-18**], she was sitting on the edge of the bed and reported having vomited though none was apparent. said she felt very tired; couldn??????t move. fell on top of daughter trying to get to the bathroom. sitting on the commode, putting feet on bed trying to get back??????clearly confused. was not actually complaining of abdominal pain. pulse was fine per neighbor who was [**name8 (md) **] rn. took her to the [**hospital1 1562**] er at 3:00 pm [**4-18**]; wbc was high; they went looking for cause of this. . reportedly has been having chronic renal failure and getting procrit in the past for anemia. . has been having high blood pressure; has been on blood pressure medication. . in the emergency department of the [**hospital1 18**], having received her from [**hospital1 1562**], her vitals were t 98.0, hr 60, bp 139/66, rr 18, o2 sat 100% ra. she was seen by surgery and [**hospital1 **] in the ed. she received zosyn although she had a stated pcn allergy; she had no apparent adverse reaction to this. . past medical history: hypothyroidism hyperlipidemia hypercholesterolemia hypertension knee replacement in the past; bilateral knee injury earlier this year, included need to reposition knee replacement had breast cancer in the past; got lumpectomy then had recurrence and declined masectomy; has been cancer-free for five years; has been on tamoxifen but now off it h/o cabg [**2189**] x3; no history of heart valve problems social history: drugs: none tobacco: none alcohol: none lives with daughter; states she usually lives alone but on further questioning reveals that nursing home would not allow her to go home on her own and required d/c to daughter family history: likely non-contributory in this [**age over 90 **] year old woman physical exam: t: 36.3 ??????c (97.4 ??????f) hr: 70 bpm bp: 181/60(91) mmhg rr: 17 insp/min spo2: 95% heart rhythm: sr (sinus rhythm) general appearance: no acute distress, slumped to side of bed while sleeping; easily aroused; appears to be hard of hearing eyes / conjunctiva: perrl head, ears, nose, throat: normocephalic cardiovascular: (s1: normal), (s2: normal), (murmur: systolic) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: present), (left dp pulse: present) respiratory / chest: (expansion: symmetric), (breath sounds: rhonchorous: ) abdominal: soft, non-tender, no(t) distended, seen post-procedure extremities: right: absent, left: absent, no(t) cyanosis skin: warm, no(t) rash: in partial exam, no(t) jaundice neurologic: attentive, follows simple commands, responds to: not assessed, oriented (to): hospital, but names incorrect hospital; date correct, movement: purposeful, tone: normal . pertinent results: [**2195-4-19**] 03:45am wbc-17.0* rbc-3.83* hgb-12.0 hct-36.7 mcv-96 mch-31.4 mchc-32.7 rdw-14.2 [**2195-4-19**] 03:45am neuts-84.4* lymphs-9.9* monos-5.6 eos-0.1 basos-0.1 [**2195-4-19**] 03:45am plt count-239 . [**2195-4-19**] 08:05am pt-15.9* ptt-29.1 inr(pt)-1.4* . [**2195-4-19**] 03:45am glucose-83 urea n-25* creat-1.6* sodium-132* potassium-3.7 chloride-95* total co2-25 anion gap-16 . [**2195-4-19**] 03:45am alt(sgpt)-388* ast(sgot)-638* alk phos-295* tot bili-4.0* [**2195-4-19**] 03:45am lipase-40 . [**2195-4-19**] 03:45am ck(cpk)-33 ck-mb-notdone [**2195-4-19**] 03:45am ctropnt-0.04* . [**2195-4-19**] 03:58am lactate-1.3 [**2195-4-19**] 03:29pm lactate-1.4 . [**2195-4-19**] 06:50am urine color-yellow appear-clear sp [**last name (un) 155**]-1.009 [**2195-4-19**] 06:50am urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-1 ph-5.0 leuk-neg [**2195-4-19**] 06:50am urine rbc-0 wbc-0 bacteria-0 yeast-mod epi-0-2 . . studies: . ruq ultrasound [**hospital1 18**] [**2195-4-19**] findings: overall evaluation is limited by bowel gas. allowing for this, no definite focal hepatic abnormality is identified. the common bile duct measures 1.2 cm with limited evaluation of the duct near the pancreatic head. the gallbladder is mildly distended and contains sludge, with perhaps a minimally thickenined wall. there is no pericholecystic fluid and son[**name (ni) 493**] [**name2 (ni) 515**] sign is negative. no free fluid is seen in the right upper quadrant. there is no right hydronephrosis. impression: 1. 1.2 cm cbd with limited evaluation of the duct near the pancreatic head. obstructive causes cannot be exlcuded and correlation with recent outside imaging is recommended. 2. distended, sludge- containing gallbladder. findings may represent early cholecystitis. [**name2 (ni) **] [**4-19**]: stones at the lower third of the common bile duct - full cholangiogram was not perfomred due to suspicion of acute cholangitis. a sphincterotomy was performed. a stent was placed. [**month/day (4) **] [**4-21**]: fresh and old blood clots were seen in the body of stomach and antrum. a plastic stent placed in the biliary duct was found in the major papilla. evidence of bleeding from the previous sphincterotomy was noted. an epinephrine injection and a gold probe was applied at the sphincterotomy site for hemostasis successfully. brief hospital course: [**age over 90 **] year old woman with past cabg now here w hx of abd pain, cbd dilatation seen at osh. now s/p [**age over 90 **] and sphincterotomy w stent. cbd dilatation and liver enzyme abnormalities/cholecystitis consistent with cholelithiasis/choledocholithiasis; labs consistent with ductal obstruction with elevated alk phos, elevated alt/ast, high bilirubin. had [**age over 90 **], sphincterotomy, stent placement [**4-19**]. surgery discussed cholecystectomy but given some reluctance by the patient and family, will not pursue this admission. the patient had a large bloody bowel movement on the medical floor [**4-21**], concerning for gib related to sphincterotomy. she was taken urgently to the gi suite for repeat [**month/day (2) **] where bleeding was found at the sphincterotomy site. epinephrine was injected and a gold probe was applied with resolution of the bleeding. she received 2 units prbc after the procedure and her hct was stable at 28-31 afterwards. she should continue on antibiotics to complete at 14-day course. she is scheduled for [**month/day (2) **] for stent removal and stone extraction. st changes non-diagnostic st changes seen on ekg in setting of hypertension and acute medical illness on admission. diffuse non-diagnostic abnormalities probably associated with demand and underlying disease but baseline risk is significant given past cabg, advanced age, htn, hyperlipidemia. repeat tnt was <0.01. she was maintained on metoprolol and aspirin until she had gib (see above) for fear of worsening the bleeding and masking tachycardia. metoprolol was restarted on discharge after she had been hemodynamically stable for three days. statin was initially held given elevated liver enzymes but may be restarted on discharge. htn elevated systolic pressure, high pulse pressure, no physical exam findings clearly assoc w ar, no known hx of valvular dz per patient and patient??????s daughter. calcified [**name2 (ni) 83221**] aorta seen on osh ct. she was intermittently on hydralazine for blood pressure control while her ramipril was held for acute renal failure and metoprolol was held (see below). these were restarted by discharge with improvement in her blood pressure. renal failure apparently a chronic issue, not clear what her baseline is, may be close to baseline at this point. improved with hydration to 1.2-1.3 and remained stable. hypothyroidism continued levoxyl. depression continued home dose of sertraline. breast cancer apparently was on tamoxifen (daughter unsure of med) for five years until a few months ago; not now. no evident recurrence. no need to pursue this in this setting; mets unlikely to be cause of current problems given ct from osh not showing lesions. medications on admission: (eventually confirmed with daughter's home list): levothyroxine 75 mcg daily metoprolol tartrate 12.5 mg daily ramipril caplets 5 mg daily simvastatin 20 mg nightly sertraline 50 mg hs prilosec discharge medications: 1. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 2. metoprolol tartrate 50 mg tablet sig: one (1) tablet po once a day. 3. ramipril 5 mg capsule sig: one (1) capsule po daily (daily). 4. simvastatin 20 mg tablet sig: one (1) tablet po at bedtime. 5. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 6. prilosec 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 7. ciprofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 9 days. 8. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 9 days. 9. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). discharge disposition: extended care facility: [**hospital 24806**] care center - [**hospital1 1562**] discharge diagnosis: primary: cholelithiasis, bleeding from sphincterotomy site, nstemi secondary: hypertension, hypothyroidism, hyperlipidemia, hypercholesterolemia, coronary artery disease discharge condition: good, stable, hematocrit stable discharge instructions: you were evaluated for abdominal pain, found to have gallstones, and transferred here for [**hospital1 **]. you had another [**hospital1 **] to correct bleeding at the sphincterotomy site and remained stable afterwards. if you have worsening abdominal pain, blood in your stool, chest pain, shortness of breath, call your doctor. followup instructions: you are scheduled for repeat [**hospital1 **] on [**5-28**]: provider: [**name initial (nameis) **] 2 (st-4) gi rooms date/time:[**2195-5-28**] 11:00 provider: [**name10 (nameis) 1948**] [**last name (namepattern4) 1949**], md phone:[**telephone/fax (1) 463**] date/time:[**2195-5-28**] 11:00 follow up with your primary care physician 1-2 weeks after discharge from rehab",0
116,"admission date: [**2139-12-9**] discharge date: [**2139-12-26**] date of birth: [**2093-11-21**] sex: m service: neurology allergies: patient recorded as having no known allergies to drugs attending:[**first name3 (lf) 2569**] chief complaint: code stroke major surgical or invasive procedure: cerebral angiogram history of present illness: the pt is a 46 year-old right-handed man with a pmh of dm and htn off medications who was transferred from [**hospital3 **] today. mr. [**known lastname **] states that he was in his usoh this morning. he came home around noon and felt tired so he took a nap. when he woke around 1 or 1:30 he noticed that his entire left arm and hand were ""numb"". he was unable to feel the arm but denied paresthesias. he was also unable to move the arm at all. he was also unable to move the hand or fingers but felt that the leg was normal. he was unaware of any facial problems though his wife noticed that his left side face was droopy. he tried to drink water and the water spilled out of the left side of his mouth. his speech was also very hard to understand and ""garbled"". he was aware of what he wanted to say and was able to speak fluently but had difficulty articulating the words. his comprehension was normal. he went to [**hospital6 5016**] where he was evaluated with screening labs with platelets of 255, a glucose of 188, nl lft's, inr of 1 and a cr of 1. his troponin was 0.04 and the ck was 76. his ecg showed sr and no st changes. a head ct was done which was read as negative, however on review on the images here, i am concerned for a r parietal area of hypodensity. clinically, mr. [**known lastname **] states that his r arm improved over half an hour. he was gradually able to raise it above his head and the numbness improved. his facial weakness and speech also improved. he was given asa 325 per report and transferred here for further care. of note, mr. [**known lastname **] states that he had had an episode of l hand numbness and weakness last week. he recalls that he was playing pool and dropped his pool stick. he went to pick it up and his l hand felt numb and weak. he was unable to move his fingers. he waited a few minutes and the symptom resolved. ros: the pt denied headache, loss of vision, blurred vision, diplopia, lightheadedness, vertigo, tinnitus or hearing difficulty. denied difficulties comprehending speech. denied paraesthesia. no bowel or bladder incontinence or retention. denied difficulty with gait. the pt denied recent fever or chills. no night sweats or recent weight loss or gain. 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. denied rash. past medical history: 1. dm 2. htn 3. boil removed social history: -etoh: [**1-20**] drinks per week -tobacco: 1 ppd x 30 years -drugs: denies -sells sporting equipment family history: -mother: dm, died of heart problems -father: died of heart problems physical exam: nih ss: 2 1a. level of consciousness: 0 1b. loc questions: 0 1c. loc commands: 0 2. best gaze: 0 3. visual: 0 4. facial palsy: 1 5a. motor arm, left: 0 5b. motor arm, right: 0 6a. motor leg, left: 0 6b. motor leg, right: 0 7. limb ataxia: 0 8. sensory: 0 9. best language: 0 10. dysarthria: 1 11. extinction and inattention: 0 vitals: t: 98.4 p: 104 r: 16 bp: 189/91 sao2: 96% 2l general: awake, cooperative, nad. heent: nc/at, no scleral icterus noted, mmm, no lesions noted in oropharynx neck: supple, no carotid bruits appreciated. no nuchal rigidity pulmonary: slight basilar crackles bilaterally cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted. extremities: no edema skin: no rashes or lesions noted. neurologic: -mental status: alert, oriented x 3. able to relate history without difficulty. attentive, able to name [**doctor last name 1841**] backward without difficulty. language is fluent with intact repetition and comprehension. normal prosody. there were no paraphasic errors. pt. was able to name both high and low frequency objects. able to read without difficulty. speech was mildly dysarthric. able to follow both midline and appendicular commands. there was no evidence of apraxia or neglect. cn i: not tested ii,iii: vff to confrontation, pupils 4mm->2mm bilaterally, fundi normal iii,iv,v: eomi, no ptosis. no nystagmus v: sensation intact v1-v3 to lt vii: l facial droop, symm forehead wrinkling viii: hears finger rub bilaterally ix,x: palate elevates symmetrically, uvula midline [**doctor first name 81**]: scm/trapezeii [**3-22**] bilaterally xii: tongue protrudes midline, no dysarthria motor: normal bulk and tone; no asterixis or myoclonus. no pronator drift. delt [**hospital1 **] tri we fe grip io c5 c6 c7 c6 c7 c8/t1 t1 l 5- 5 5 5 5 5 5 r 5 5 5 5 5 5 5 ip quad hamst df [**last name (un) 938**] pf l2 l3 l4-s1 l4 l5 s1/s2 l 5 5 5 5 5 5 r 5 5 5 5 5 5 reflex: no clonus [**hospital1 **] tri bra pat an plantar c5 c7 c6 l4 s1 cst l 1------------ 0 flexor r 1------------ 0 flexor -sensory: no deficits to light touch, pinprick, cold sensation or proprioception throughout. slightly decreased vibratory sense in le bilaterally. no extinction to dss. -coordination: no intention tremor, dysdiadochokinesia noted. no dysmetria on fnf or hks bilaterally. -gait: deferred in the context of acute stroke pertinent results: [**2139-12-9**] 06:25pm blood wbc-9.2 rbc-4.68 hgb-14.8 hct-39.7* mcv-85 mch-31.6 mchc-37.3* rdw-13.4 plt ct-272 [**2139-12-9**] 06:25pm blood pt-12.4 ptt-25.7 inr(pt)-1.0 [**2139-12-13**] 01:41am blood esr-13 [**2139-12-9**] 06:25pm blood glucose-131* urean-12 creat-1.0 na-134 k-4.1 cl-96 hco3-28 angap-14 [**2139-12-9**] 06:25pm blood ctropnt-<0.01 [**2139-12-10**] 05:20am blood ctropnt-<0.01 [**2139-12-13**] 02:57pm blood ck-mb-notdone ctropnt-<0.01 [**2139-12-10**] 05:20am blood %hba1c-6.9* [**2139-12-10**] 05:20am blood triglyc-206* hdl-42 chol/hd-4.9 ldlcalc-123 [**2139-12-13**] 01:41am blood tsh-10* [**2139-12-14**] 03:35pm blood t4-7.7 t3-98 [**2139-12-9**] 06:25pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg [**2139-12-13**] 01:41am blood pep-no specifi igg-1038 iga-124 igm-97 ife-no monoclo ct brain perfusion: 1. right mca territory infarct, with abrupt cut off of the right mca in the region of its bifurcation, with m1 segment not identified. m2 branches are seen, suggesting a nearly occlusive filling defect/embolus within the right m1 segment. corresponding increased transit time is identified in the right mca territory. 2. no acute hemorrhage. 3. diminuative a1 vessels, with poor filling of the proximal a2 branches. better filling is identified in the more distal a2 vessels, suggesting posterior pericallosal collateral filling. 4. stenosis at the origin of the left vertebral artery, which arises from the aortic arch. mri/a of head: 1. findings consistent with infarcts in the right mca territory, with abrupt cutoff of the right mca identified on mra at the bifurcation. findings on previously performed cta suggest that there is collateral filling of more distal m2 branches, although those are not identified on this study. 2. a1 and a2 branches not identified on the current mra, although findings on prior cta suggest posterior pericallosal collateral filling of the distal a2 vessels. 3. no acute hemorrhage. echo: severe regional left ventricular systolic dysfunction (lvef 30%) not consistent with ischemic cardiomyopathy. severe diastolic dysfunction. mild mitral regurgitation. no pfo/asd identified. angiogram: r mca occlusion and both acas not visualized. unable to stent ot intervene otherwise. brief hospital course: the pt is a 46 year-old rh man with a pmh of dm and htn, untreated. he developed left arm weakness and numbness as well as a facial droop with gradual improvement of his symtpoms. on arrival, in the ed, his bp ranged between 170-200's and he was in sinus tachycardia with a rate of 100's. his exam was notable for a l facial droop, mild dysarthria and slight l deltoid weakness (-5). he did not have any extinction or sensory loss and no drift. his leg was normal. his nihss was 2. he was taken urgently to ct/cta and ctp which showed an evolving hypodensity on the r parietal lobe and an m1 cut off on cta. his ctp showed a delay in mtt and a decrease in both cbv and cbf however with a mismatch, concerning for a residual penumbra. these results were reviewed with the o/c radiologist, as well as the stroke fellow who discussed the results with the stroke attg. as his symptoms improved clinically with little deficit, he was not given ia tpa and admitted to the icu with heparin drip. patient was also found to have cardiomyopathy with lvef of 30% - echo was most consistent with restrictive cardiomyopathy but not in coronary distribution hence cardiology consult recommended initial labs that were all normal except for elevated tsh. however, free t4 and t3 were within normal range hence this is expected in acute illness. cardiology agreed with plan for repeat echo in 2 months. during the icu stay, he continued to have mildly fluctuating mental status with transient worsening of left sided weakness. he was successfully transferred to the step-down unit where he was noticed to have significant but transient change in confusion, facial droop and weakness in the setting of receiving anti-hyperntensive [**doctor last name 360**]. he had repeat scan which showed expansion of ischemia and he underwent repeat angiogram which showed r mca occlusion without visualization of both acas but no intervention was possible. given such finding, his episodes of confusion and worsening weakness most likely due to hypoperfusion of his acas in the setting lower blood pressure hence he was treated with goal sbp ~150 with ivf and bedrest. on [**12-21**], he was also started on low dose midodrine, 2.5mg [**hospital1 **] for increased bp with parameters to prevent supine htn. he remained stable and he began working with pt to ambulate assistance on [**12-24**] without adverse reaction. as for his r mca occlusion and underperfusion of both acas, dr. [**last name (stitle) 81712**] at [**hospital1 2025**] was contact[**name (ni) **] for possible consideration of bypass surgery who felt that the surgery was viable and safe but unclear of its efficacy. upon discussing with family of the surgery option, family decided that they would like to proceed with this and transfer was facilitated. medications on admission: none discharge medications: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 2. atorvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 3. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 4. warfarin 5 mg tablet sig: one (1) tablet po once daily at 4 pm. 5. midodrine 5 mg tablet sig: 0.5 tablet po bid (2 times a day). 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed. 7. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 8. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 9. menthol-cetylpyridinium 3 mg lozenge sig: one (1) lozenge mucous membrane prn (as needed). discharge disposition: extended care discharge diagnosis: r m1 mca occlusion hypertension diabetes mellitus discharge condition: stable but transiently increased confusion, worsening of l facial droop with weakness usually in the setting of lower blood pressure or standing. discharge instructions: you presented with l arm weakness and numbness as well as a facial droop with gradual improvement of your symtpoms. upon arrival, your exam was notable for a l facial droop, mild dysarthria and slight l deltoid weakness (-5) and your nihss was 2. you were taken urgently to ct/cta and ctp which showed an evolving hypodensity on the r parietal lobe and an m1 cut off on cta but given that your symptoms improved clinically with little deficit, you did not get ia tpa and you were admitted to the icu with heparin drip. you remained stable but with fluctuating exam including confusion, left facial droop with left sided weakness. after being transferred the neurology floor, you had an episode of prolonged confusion with definite l facial droop hence you had urgent imaging showing worsening of infarct and repeat angiogram showed r mca occlusion plus non-visualization of both acas but due to the location and already completed infarct, no intervention was possible. you remained in the neurology floor with goal of sbp 150~180. given the findings, dr. [**last name (stitle) **] at [**hospital1 2025**] was contact[**name (ni) **] for possible bypass surgery and upon reviewing the films plus history, dr. [**last name (stitle) **] consented to transfer of the patient for possible consideration of the surgery given likely low risk although efficacy unclear. you continued to have fluctuating exam in the setting of decreased bp or standing position. to increase blood pressure in hopes of ensuring adquate cerebral perfusion, midodrine was started on [**12-21**] with parameters to prevent supine hypertension. you have also been started on coumadin with heparin bridging and your inr has been therapeutic over 1 week by the time of your discharge. followup instructions: provider: [**first name11 (name pattern1) **] [**last name (namepattern4) 13960**], md phone:[**telephone/fax (1) 250**] date/time:[**2140-2-25**] 11:00 provider: [**name10 (nameis) 900**] [**name8 (md) 901**], m.d. phone:[**telephone/fax (1) 62**] date/time:[**2140-2-11**] 3:00 [**first name8 (namepattern2) **] [**name8 (md) 162**] md [**md number(2) 2575**]",0
117,"admission date: [**2159-8-12**] discharge date: [**2159-8-16**] service: medicine allergies: pneumococcal vaccine / influenza virus vaccine / sulfa (sulfonamides) / penicillins attending:[**first name3 (lf) 13386**] chief complaint: brbpr and coffee ground emesis major surgical or invasive procedure: lij was placed transfusion of 5 units of prbcs history of present illness: [**age over 90 **] yo f with a history of cad, cva, gerd, mrsa uti, dm, and dementia (verbal but confused at baseline) presents to ed from from heb reb, with hypotension. she had one episode of emesis (non bloody [**8-11**]). she then reportedly complained of abd pain on the day of admission ([**8-12**]), then had 1 episode of coffee ground emesis, followed by brbpr with clots. her bp at the [**hospital1 1501**] was 60/p. . on arrival to the ed her blood pressure was 80/palp. [**hospital1 **] was 26 (was 33 on [**2158-8-9**]), lactate was 5.5, ua was grossly positive. fast was negative. abd ct revealed 2 cm clot vs mass in duodenum. gi and surgery were consulted. she was fluid resucutated, and initially her bp improved to 100 systolic, but then trended down to 70's. . potassium was initially 7.6, she was given calcium cl 1 g, insulin 5u. code sepsis was called, a l ij was placed (following a failed attempt at a r ij). she was given 3.2l ivf, vanco/levo/flagyl and transfused 2 units prbcs. on transfer to the micu she was afebrile hr 110, bp 90-100/40, satting 97% 2l nc. . ros: unable to obtain . past medical history: cad s/p angioplasty [**2143**] h/o cva dm2 with peripheral neuropathy (hgba1c = 6.6) ckd (b/l cr 1.8) diverticulitis s/p partial colectomy chronic hypotension (b/l bp = 90) hyperlipidemia dementia (oriented x 1 at baseline) h/o chronic anemia h/o mrsa uti recent cdiff (last dose [**2159-8-10**]) possible chronic renal failure gerd sle h/o gallstone pancreatitis copd oa h/o cystitis low back pain h/o r knee surgery s/p sympathectomy social history: from [**hospital 100**] rehab, former smoker- [**12-6**] ppd x 80 years. no etoh. uses a walker. son [**name (ni) **] is hcp. requires assistance for adl's, family history: nc physical exam: vs - temp 97.3 f, bp 112/80, hr 102, r 18, o2-sat 96% ra gen: sleepy but arousable--lapses back into sleep easily, oriented x1 to self only. follows simple commands, frail elderly woman, confused, moaning, very hard of hearing heent: [**last name (lf) 12476**], [**first name3 (lf) 13775**], eomi, anicteric , dry mm , op clear neck: supple, no jvd, no bruits, no lad heart: rrr, s1, s2, 2/6 sem at base, no ectopy lungs: crackles at b/l bases; no rh/wh, no accessory muscle use abd: generally tender/no rebound/no guard. no mass; no organomegaly; obese; bruisig of skin at site of medication injection. ext: no cce/erythema (blanching) rt foot; dp/pt dopplerable skin: stage i-ii sacral decub neuro: aa&ox1(to name), 5/5 strength arms; 4/4 strength both legs; cn2-12 grossly normal except for left hearing loss; babinski downgoing bilat. reflexes hard to elicit. pertinent results: ekg: sinus tach at 108, 1st degree av block, nonspecific stt changes . [**2159-8-14**]: baseline artifact. sinus rhythm. leftward axis. since the previous tracing the axis is more leftward. . ct pelvis w/o contrast [**8-12**]: 4 cm hyperdense collection in the duodenum is concerning upper gi bleed(likely bleeding duodenual ulcer, but cannot rule out underlying mass). no intraperitoneal free fluid, free air or obstruction. . . [**2159-8-12**] 02:32pm glucose-251* urea n-47* creat-1.7* sodium-137 potassium-5.5* chloride-111* total co2-21* anion gap-11 [**2159-8-12**] 02:32pm calcium-6.5* phosphate-4.4 magnesium-1.4* [**2159-8-12**] 02:32pm wbc-14.9* rbc-3.10* hgb-9.4* [**month/day/year **]-27.2* mcv-88 mch-30.3 mchc-34.5# rdw-15.5 [**2159-8-12**] 02:32pm plt count-222 [**2159-8-12**] 01:07pm lactate-1.5 [**2159-8-12**] 11:27am lactate-2.6* [**2159-8-12**] 09:45am lactate-2.9* [**2159-8-12**] 09:30am urine color-yellow appear-cloudy sp [**last name (un) 155**]-1.015 [**2159-8-12**] 09:30am urine blood-lg nitrite-pos protein-30 glucose-neg ketone-tr bilirubin-sm urobilngn-neg ph-5.0 leuk-mod [**2159-8-12**] 09:30am urine rbc-[**5-15**]* wbc->50 bacteria-many yeast-none epi-[**2-7**] [**2159-8-12**] 08:10am glucose-267* urea n-46* creat-2.0* sodium-138 potassium-5.6* chloride-108 total co2-25 anion gap-11 [**2159-8-12**] 08:10am estgfr-using this [**2159-8-12**] 08:10am alt(sgpt)-9 ast(sgot)-12 ck(cpk)-17* alk phos-43 tot bili-0.3 [**2159-8-12**] 08:10am lipase-16 [**2159-8-12**] 08:10am ck-mb-notdone [**2159-8-12**] 08:10am albumin-1.9* calcium-6.0* phosphate-4.7* magnesium-1.5* [**2159-8-12**] 08:10am cortisol-27.3* [**2159-8-12**] 08:10am cortisol-27.3* [**2159-8-12**] 08:10am crp-3.4 [**2159-8-12**] 07:19am lactate-5.5* k+-7.6* [**2159-8-12**] 07:15am ctropnt-0.03* [**2159-8-12**] 07:15am wbc-12.7* rbc-2.93* hgb-8.1* [**month/day/year **]-26.1* mcv-89 mch-27.8 mchc-31.2 rdw-16.8* [**2159-8-12**] 07:15am neuts-81.2* lymphs-14.8* monos-3.1 eos-0.1 basos-0.8 [**2159-8-12**] 07:15am plt count-440 [**2159-8-12**] 07:15am pt-12.9 ptt-25.7 inr(pt)-1.1 . complete blood count wbc rbc hgb [**month/day/year **] mcv mch mchc rdw plt ct [**2159-8-16**] 10:50am 34.9* [**2159-8-16**] 05:55am 7.9 3.82* 11.4* 33.7* 88 29.8 33.8 16.5* 138* [**2159-8-16**] 04:06am 8.5 4.02* 11.7* 36.4 90 29.1 32.2 16.3* 155 [**2159-8-15**] 03:40pm 8.4 3.96* 12.1 36.1 91 30.5 33.5 16.2* 154 source: line-central [**2159-8-15**] 06:10am 8.3 4.11* 12.2 36.1 88 29.6 33.7 16.4* 188 [**2159-8-15**] 12:18am 35.3* source: line-cvl [**2159-8-14**] 03:22pm 35.7* source: line-central [**2159-8-14**] 05:56am 12.3* 3.62* 11.0* 31.6* 87 30.2 34.7 16.2* 203 source: line-cvl [**2159-8-13**] 11:23pm 32.8* [**2159-8-13**] 07:28pm 33.9* source: line-central [**2159-8-13**] 04:36pm 17.1* 4.10* 11.9* 35.7* 87 29.1 33.4 16.0* 190 source: line-cvl [**2159-8-13**] 02:23pm 33.3* source: line-left ij [**2159-8-13**] 09:28am 35.1* source: line- left ij [**2159-8-13**] 05:56am 15.4* 4.17*# 12.3# 35.7* 86 29.5 34.4 15.8* 196 . . renal & glucose glucose urean creat na k cl hco3 angap [**2159-8-16**] 05:55am 101 28* 1.3* 141 4.81 110* 19* 17 [**2159-8-15**] 06:10am 113* 39* 1.4* 142 4.6 112* 22 13 [**2159-8-14**] 05:56am 157* 51* 1.5* 141 4.7 112* 20* 14 source: line-cvl [**2159-8-13**] 04:36pm 196* 57* 1.6* 138 5.3* 109* 20* 14 source: line-cvl [**2159-8-13**] 02:23pm 152* 58* 1.5* 137 5.7* 111* 21* 11 source: line-left ij [**2159-8-13**] 09:28am 5.7* source: line- left ij [**2159-8-13**] 05:56am 177* 62* 1.6* 136 5.8* 109* 21* 12 source: line-central [**2159-8-12**] 02:32pm 251* 47* 1.7* 137 5.5* 111* 21* 11 source: line-tlc [**2159-8-12**] 08:10am 267* 46* 2.0* 138 5.6* 108 25 11 . . . cortisol [**2159-8-12**] 08:10am 27.3*1 . lactate: [**2159-8-12**] 01:07pm 1.5 [**2159-8-12**] 11:27am 2.6* [**2159-8-12**] 09:45am 2.9* [**2159-8-12**] 07:19am 5.5* . alt ast ck alkphos totbili [**2159-8-12**] 9 12 17 43 0.3 . final [**year (4 digits) **] on discharge 34.9 . [**2159-8-15**] catheter tip-iv wound culture-preliminary inpatient [**2159-8-15**] blood culture blood culture, routine-pending inpatient [**2159-8-14**] blood culture blood culture, routine-pending inpatient [**2159-8-14**] blood culture blood culture, routine-pending inpatient [**2159-8-14**] blood culture blood culture, routine-pending inpatient [**2159-8-12**] urine urine culture-final {escherichia coli, escherichia coli} emergency [**hospital1 **] [**2159-8-12**] blood culture blood culture, routine-pending emergency [**hospital1 **] [**2159-8-12**] blood culture blood culture, routine-preliminary {lactobacillus species}; aerobic bottle gram stain-final emergency [**hospital1 **] . urine culture (final [**2159-8-15**]): escherichia coli. >100,000 organisms/ml.. escherichia coli. >100,000 organisms/ml.. 2nd morphology. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | escherichia coli | | ampicillin------------ 16 i <=2 s ampicillin/sulbactam-- 8 s <=2 s cefazolin------------- <=4 s <=4 s cefepime-------------- <=1 s <=1 s ceftazidime----------- <=1 s <=1 s ceftriaxone----------- <=1 s <=1 s cefuroxime------------ 16 i 4 s ciprofloxacin--------- =>4 r =>4 r gentamicin------------ <=1 s <=1 s meropenem-------------<=0.25 s <=0.25 s nitrofurantoin-------- <=16 s <=16 s piperacillin---------- <=4 s <=4 s piperacillin/tazo----- <=4 s <=4 s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- <=1 s <=1 s brief hospital course: [**age over 90 **]f presents with history of gerd, dementia, mrsa uti admitted to micu from [**hospital1 1501**] with shock, uti and gi bleed. . # sepsis/uti/bacteremia - initially hypotensive in ed, baseline [**hospital1 **] per her pcp [**last name (namepattern4) **] 36, down to 26 on admission, thus hypotension felt most likely hypovolemic from gi bleed, but may have had septic component as well given +ua on [**8-12**], +leukocytosis (wbc 17.1). cvp = 4. given 3.2 l ivf, 2 units prbc's in ed. never required pressors in the icu. she recieved ~4l ivf in the micu, and 4u prbcs. she was treated with broad spectrum abx vanc/cipro/flagyl for 1d in the icu. she was transferred to the floor on [**2159-8-13**]. vanco and flagyl were discontinued given the presence of gram negative rods on urine culture, and no other source of infection. her urine speciated e.coli resistant to quinolones, and she was switched to oral bactrim based on sensitivities. she has a history of reported bactrim allergy. after discussion with her pcp, [**name10 (nameis) **] was determined that she has taken bactrim in the past in [**4-10**] without adverse reaction. she tolerated bactrim without difficulty. . blood cultures on [**2159-8-12**] were positive for lactobacillus in 1 of 2 bottles. subsequent cultures on [**9-8**], [**8-15**] showed no growth at the time of discharge. left ij catheter tip was cultured and showed no growth at the time of discharge. id consult was obtained, and recommended clindamycin iv x 14 days to treat potential lactbacillus bacteremia starting on [**8-16**]. a picc line was placed for this antibiotic. she was also started on a 21 day course of oral vancomycin (starting [**8-16**]) for c. difficile prophylaxis given her recent c. difficille infection. she was hemodynamically stable upon transfer to the medical floor and had no further hypotension. . she should have follow-up of her bacteremia with either her primary care physician or the gerontology service at [**hospital 100**] rehab. she does not require surveillence cultures. . # gib bleed - most likely due to duodenal ulcer given ct scan. gi and surgery were consulted, and given the patient and son's desire for conservative management, it was agreed upon that no intervention would be performed unless pt developed life threatening bleed. pt received total of 5u prbcs last on [**8-14**]. her [**month/day (4) **] was stable at 33-35 on discharge on [**8-16**]. she was tolerating a regular pureed diet with supervision given concern for aspiration while recovering from uti. she was discharged home on omeprazole twice daily. her aspirin and plavix were discontinued. she should discuss restarting her aspirin with her primary care physician in the future. . . # hyperkalemia - k up to 5.8 on [**8-13**], down to 4.8 on [**8-16**] without intervention. no ekg changes. some question of rta as source of chronic hyperkalemia. potassium resolved without intervention. she will follow-up with her pcp. . . # recent c diff - pt finished po vancomycin [**8-10**]. she had melanotic stools this admission, though no diarrhea. she was started on po vanco on [**8-16**] for 21 day course to prophylax against cdiff given that she is starting a new course of bactrim for uti and clindamycin for bacteremia. . . # ckd: baseline cr 1.8 per report, down to 1.3 on [**8-16**]. medications were renally dosed. no evidence of atn. . # dm - pt was covered with sliding scale insulin while inpatient. . # gout - pt continued home regimen of allopurinol. . # anemia - baseline hgb is approximately 12 per discussion with patients' pcp. [**name10 (nameis) **] down to 26 on admission consistent with gib. at time of discharge [**name10 (nameis) **] 34.9. iron supplementation was held in setting of gib, and can be restarted as outpatient. . # cad - given ongoing gib as above, decision made to hold aspirin and plavix. no clear indication for continue plavix given lack of recent nstem, cva, or pad. pt will need to discuss restarting aspirin with pcp once hematocrit has been stable. . # copd - pt continued on her home regimen of fluticasone and spiriva. she was breathing comfortably on room air at the time of discharge. . # access - l ij placed in setting of hypotension in icu. this was discontinued on [**8-15**], and tip was cultured. picc was placed for iv antibiotics which will continue for 14 days, afterwhich time picc can be discontinued. . # fen - pt advanced to regular pureed diet on [**8-15**]. pt kept on aspiration precautions given that she remains drowsy in setting of her uti. . # code: pt's code status was made dnr/dni per discussion with son, hcp in keeping with patient's wishes. son is hcp. . # dispo: pt being discharged to [**hospital 100**] rehab. plan is to complete antibiotics as above (bactrim for uti, clindamycin for lactobacillus bacteremia), and oral vancomycin for cdiff prophylaxis. she will readdress aspirin use as above. medications on admission: tylenol spiriva aspirin 81 mg feso4 daily plavix 75 mg fluticasone 220 mcg 1 puff [**hospital1 **] milk of mag trazodone 50 hs prn allopurinol 100 mg daily hiss prilosec tums [**hospital1 **] vit d 1000u dialy maalox prn lactobacillus [**hospital1 **] discharge medications: 1. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain. 3. iron (ferrous sulfate) 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 4. fluticasone 110 mcg/actuation aerosol sig: two (2) puff inhalation [**hospital1 **] (2 times a day). 5. allopurinol 100 mg tablet sig: one (1) tablet po daily (daily). 6. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po bid (2 times a day) for 8 days: allegy noted. pcp said that he has never documented a reaction to it. 7. insulin lispro 100 unit/ml solution sig: one (1) units subcutaneous asdir (as directed). 8. vitamin d 1,000 unit capsule sig: one (1) capsule po once a day. 9. maalox 200-200-20 mg/5 ml suspension sig: one (1) po every 4-6 hours as needed for heartburn. 10. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 11. vancomycin 250 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 21 days: last day [**2159-9-5**]. 12. clindamycin phosphate 150 mg/ml solution sig: one (1) 600mg injection q8h (every 8 hours) for 14 days: 600 mg iv q8hr, last day [**2159-8-29**]. discharge disposition: extended care facility: [**hospital3 **] center discharge diagnosis: primary diagnosis: upper gi bleed urinary tract infection bacteremia . secondary diagnosis: coronary artery disease dementia discharge condition: you are being discharged at your baseline level of functioning. your vital signs are stable and you have been assessed by physical therapy. discharge instructions: you were admitted after an ulcer in your gi tract bled enough that your vital signs become unstable and you required admission to the intensive care unit. after blood transfusions and careful monitoring, your vital signs stabilized and you were followed on the regular floors. you were also treated with antibiotics for a urinary tract infection and an infection in your blood stream. . the following changes were made to your medications"" 1)you will need to take bactrim for your urinary tract infetion. please take 1 tablet by mouth twice a day for the next 8 days to end on [**2159-8-15**]. 2)we have discontinued your plavix, the milk of magnesia, tums, and lactobacillus. 3)please discuss with your rehab doctors when to [**name5 (ptitle) **] your aspirin. 4)the prilosec should now be taken twice a day by mouth. 5)please take clindamycin 600mg iv every 8 hours for 5 days to end [**2159-8-20**]. this is the treat the bacteria in your blood. 6)please take vancomycin 250mg by mouth 4 times a day for 12 days to end on [**2159-8-28**]. this is to prevent you from getting diarrhea from your other antibiotics. . you will be followed by the doctors [**first name (titles) **] [**last name (titles) 100**] rehab. . if you develop any of the following: chest pain, shortness of breath, palpataion, dizziness, nausea or vomiting, or bloody stools, please notify the doctors at rehab [**name5 (ptitle) **] go to your local emergency room. followup instructions: the doctors at rehab [**name5 (ptitle) **] take care of you and will make recommendations that your should follow. completed by:[**2159-8-16**]",0
118,"admission date: [**2190-3-5**] discharge date: [**2190-3-12**] service: neurology allergies: patient recorded as having no known allergies to drugs attending:[**last name (namepattern1) 1838**] chief complaint: left sided weakness major surgical or invasive procedure: none history of present illness: the pt is an 85 year-old right-handed man with a pmh of pd and dementia who was transferred from [**hospital3 10310**] hospital with an ich. this history is obtained from the patients wife, osh records and the patient. per the records, he reported a fall 1 week ago in the bathtub. this morning he woke up and his wife heard him walk to the bathroom and back (they sleep in separate rooms). she then went to check on him around 4:30am and found him complaining that he was cold. she noticed that he wasn't really moving the l side. she made him coffee and put him back to bed. later that morning she was trying to get him changed out of pajamas and when he stood up he fell forward onto his face. there was no loc. they therefore took him to an osh. there his bp was highest at 206/87. he had screening labs including an inr of 1.1 and platelets of 177. a head ct was done which showed a r parietal bleed, he was give cerebryx 1gm and he was transferred here for further care. of note, he has a history of falls and slipped in the bathroom 1-2 weeks ago, but had no loc and was baseline afterward ros: (per wife) denied headache, loss of vision, dysarthria, dysphagia, lightheadedness. denied difficulties producing or comprehending speech. + chronic constipation. denied recent fever or chills. no night sweats or recent weight loss or gain. denied cough, shortness of breath. denied chest pain or tightness, palpitations. denied arthralgias or myalgias. denied rash. past medical history: - htn - hx of falls - hernia bilaterally (?) - cataracts surgery - glaucoma - vein stripping - gi polyps - ""prostate problems"", not ca per wife social history: -lives with his wife and is independent in his adls -alcohol: denies -tobacco: denies -drugs: denies family history: non contributory physical exam: vitals: t: 98.4 p: 56 r: 16 bp: 158/73 sao2: 100 general: awake, cooperative, nad. heent: nc/at, no scleral icterus noted, mmm, no lesions noted in oropharynx neck: decreased rom in all directions, no carotid bruits appreciated. pulmonary: lungs cta bilaterally without r/r/w cardiac: nl. s1s2 abdomen: soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted. extremities: no edema. skin: scars over knees neurologic: -mental status: alert, requesting repeatedly to go to the bathroom and insisting that he cannot use a bed pan. oriented to person, hospital and [**month (only) 958**] but not day or year. unable to provide details of history. language is fluent with intact repetition and comprehension. normal prosody. there were no paraphasic errors. pt does not cooperate with all aspects of the exam but is able to name high frequency objects and follow simple commands. reads without difficult as well. pt always looking to the r side of room but when prompted does attend to the l side and is able to turn head to look to the l. does not move the l hand or leg spontaneously. when asked why he is here he notes that there is something wrong with the l side but does not understand why he can't get up to go to the bathroom and says he can walk ""fine"". cn i: not tested ii,iii: blinks to threat inconsistently, does not cooperate with vf testing. pupils ovid and surgical bilaterally, unable to visualize fundi iii,iv,v: eomi, no ptosis. no nystagmus v: sensation intact v1-v3 to lt vii: facial strength intact/symmetrical, symm forehead wrinkling viii: hears finger rub bilaterally ix,x: palate elevates symmetrically, uvula midline [**doctor first name 81**]: scm/trapezeii [**4-13**] bilaterally xii: tongue protrudes midline, no dysarthria motor: normal bulk, increased tone (?paratonia vs rigidity) in all extremities w/ + cogwheeling in r wrist. r resting tremor. pt does not cooperate with formal strength testing but is briskly antigravity on the l arm and leg. the r arm falls to the bed when picked up and the l leg moves antigravity < 5 seconds when prompted. however with nox stim, the pt moves his l fingers and flexes at the elbow. he does not improve however when his hand is shown to him. reflex: no clonus [**hospital1 **] tri bra pat an plantar c5 c7 c6 l4 s1 cst l 2 2 2 0 0 up r 2 2 2 0 0 up -sensory: no deficits to nox stim throughout, does not cooperate with other modalities consistently. + extinction to dss on the l -coordination: pt does not cooperate with testing. -gait: deferred given weakness pertinent results: [**2190-3-5**] 01:20pm blood wbc-9.4 rbc-4.31* hgb-13.8* hct-39.9* mcv-92 mch-32.0 mchc-34.6 rdw-14.3 plt ct-187 [**2190-3-5**] 01:20pm blood pt-13.2 ptt-29.4 inr(pt)-1.1 [**2190-3-5**] 01:20pm blood glucose-109* urean-15 creat-1.0 na-145 k-4.0 cl-107 hco3-27 angap-15 [**2190-3-5**] 01:20pm blood alt-20 ast-21 ck(cpk)-59 alkphos-202* totbili-0.4 [**2190-3-5**] 01:20pm blood ctropnt-<0.01 [**2190-3-6**] 02:30am blood triglyc-63 hdl-39 chol/hd-2.7 ldlcalc-53 [**2190-3-6**] 02:30am blood %hba1c-5.6 ct head ([**3-6**]): 1. right parieto-occipital intraparenchymal hemorrhage, with moderate surrounding edema and local mass effect. 2. small overlying subarachnoid hemorrhage. mri/a of head ([**3-6**]): limited study with only flair t1 and diffusion images acquired. right parietal hematoma is visualized. no underlying infarct seen. somewhat most-limited mra of the head without significant abnormalities. ct head ([**3-8**]): no new areas of hemorrhage. brief hospital course: the pt is an 85 year-old rh man with a pmh of pd and dementia who was transferred from an osh after being found to have a r parietal bleed. he reportedly was in his usoh yesterday and was able to walk this morning, however when his wife checked on him around 4:30 he was unable to move his l side. he then fell later in the morning while trying to change clothing. he was found to have a large r parietal superficial bleed with a small amount of sah. he was also hypertensive initially. on exam, he has l sided weakness, neglect and possible agnosia. given his presentation and location of bleeding plus his age, this is most likely amyloid angiopathy. underlying abnormal vessels or mass were ruled out with mri/a of the head. although he did not require intubation, given bleed he was initially admitted to the icu where he remained stable overnight then subsequently transferred to the step down unit. patient was also enrolled in the deferoxime in ich trial for which he received total 3 days of deferoxime infusion from 3/27~[**3-7**] without adverse reaction. he is being followed up for these studies by his stroke physician, [**initials (namepattern5) **] [**last name (namepattern5) **]. patient was admitted to the stepdown unit for 3 days. systolic blood pressure was in the range of 170-150. on [**2190-3-8**] atenolol was discontinued and metoprolol was started. constipation was an issue on the floor, he was put on an aggressive bowel regimen which helped his bowels, and he has had bowel movements daily over the past 3 days. he was sleepy on keppra, therefore, it was stopped, he had no seizures on the floor. medications on admission: simvastatin 40 mg daily atenolol 25 mg daily aspirin 81 mg daily seroquel 25 mg daily exelon patch xalatan 0.005% 2.5 drops each eye daily combigan 0.2/0.05% 1 drop each eye daily miralax colace osteo biflex centrum silver ""sleeping pill"" discharge medications: 1. latanoprost 0.005 % drops sig: one (1) drop ophthalmic hs (at bedtime). 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 3. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 4. timolol maleate 0.5 % drops sig: one (1) drop ophthalmic [**hospital1 **] (2 times a day). 5. exelon 9.5 mg/24 hour patch 24 hr sig: one (1) transdermal qday (). 6. brimonidine 0.15 % drops sig: one (1) drop ophthalmic [**hospital1 **] (2 times a day). 7. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). 8. polyethylene glycol 3350 100 % powder sig: one (1) po daily (daily). 9. carbidopa-levodopa 25-100 mg tablet sig: one (1) tablet po tid (3 times a day). 10. erythromycin 250 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po tid (3 times a day). discharge disposition: extended care facility: [**location (un) 511**] [**hospital 62289**] hospital at [**location (un) 4047**] discharge diagnosis: primary right parietal hemorrhage presumed amyloid angiopathy constipation secondary hypertensive disorder parkinson's disease dementia discharge condition: left hemiparesis with neglect discharge instructions: you were admitted to the hospital after sudden onset of left sided weakness. you had a head ct which showed large bleeding in the right side of your brain. you were admitted to the icu for a few days and then transferred to the floor, subsequent ct showed stable hemorrhagic lesion. if you have worsening of your symptoms, please go to your nearest er. followup instructions: provider: [**name10 (nameis) 4267**] [**last name (namepattern4) 4268**], md, phd[**md number(3) 708**]:[**telephone/fax (1) 657**] date/time:[**2190-4-7**] 1:00 completed by:[**2190-3-12**]",0
119,"admission date: [**2183-1-5**] discharge date: [**2183-1-11**] date of birth: [**2107-1-16**] sex: m service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**last name (namepattern1) 1167**] chief complaint: shortness of breath major surgical or invasive procedure: cardiac catheterization with des to rca and poba to pda history of present illness: 75 m h/o severe cad s/p cabg [**2167**], s/p recent complicated admission ([**date range (1) 107779**]/07) for nstemi with multiple interventions, presented to ed after calling ems c/o increased sob. patient reports that he had noticed increased ble edema over the last few days pta. yesterday, he noted more sob and diaphoresis. pt reported taking slntg x3 at home with some relief of these symptoms. bp 160/80, rr 36, o2sat 91-92% in field per micu note. patient reports being compliant with his medications and denies any change in diet recently. he did have 1 week of a nonproductive cough. in the ed, hr 63, bp 143/77, sao2 85% ra, increasing to 90-92% on nonrebreather (no t recorded). pt refused cpap, stated that he would prefer intubation, and was ultimately intubated for increasing wob/sob. pt then received furosemide 80 mg iv, nitro gtt, and asa 300mg pr. tropt 0.03 noted on first set of ce. he put out only 200ml to the furosemide. he was transferred to the micu. in the micu, he received diuril 250mg and furosemide 100mg iv once. to this he has continually put out urine to over 2.5l negative thus far. he was awake and alert the morning after admission and was extubated at 9am. since then, he has not received any more diuretics, but continues to make urine. he has been on room air with sats in the 90's. currently, he complains of some bilateral leg pain secondary to the swelling. no cp, no sob, no n/v, no f/c, no diarrhea or abdominal pain. +sore throat from intubation. past medical history: past medical history: 1. coronary artery disease ---cabg ([**2167**]) - lima-->lad - svg-->rca - svg-->om ---pci ([**11/2176**]) - ostial lima-lad stent --> restenosis and brachytherapy ([**5-/2177**]) - stenotic lima to the lad stented - svg to the pda (patent) - svg to the rca (occluded) ---pci ([**1-/2180**]) - svg-rca and svg-om (occluded) - lima-lad (patent) - rca and r-pda stented (des) ---pci ([**3-/2180**]) - rpda stented stented (taxus) - r-pl balloon rescue - ostial rca stented (des) ---pci ([**5-/2180**]) - lmca-lcx stented (des) - rca stented (des) ---pci ([**5-/2181**]) - left subclavian artery stented - [**name (ni) 107781**] ptca ---pci ([**8-/2182**]) - rpda poba - rca poba ---pci ([**8-/2182**]) - ostial lima stented (cypher des) . 2. congestive heart disease - systolic and [**last name (lf) 107778**], [**first name3 (lf) **] 23% ([**9-16**]) 3. valvular disease - 1+ ar - 2+ mr 4. atrial fibrillation 5. episode of atrial tachycardia ([**2181**]) 6. episode of phase 4 block secondary to pvc ([**9-/2182**]) . cardiac risk factors: (+) diabetes (+) dyslipidemia (+) hypertension . other past history 1. peripheral [**year (4 digits) 1106**] disease - right cea ([**7-/2168**]) - left fem-bk [**doctor last name **] w/ issvg ([**8-/2168**]) - left fem-pt w/ vein ([**12-11**]) - right cfa-ak [**doctor last name **] w/ nrsvg ([**1-11**]) - bilateral 5th toe amps ([**1-11**]) - successful atherectomy of the right anterior tibial and popliteal arteries ([**3-14**]) - successful cryoplasty of the l fem-[**doctor last name **] graft ([**4-13**]) 2. chronic kidney disease 3. grade ii internal hemrohrroids 4. colonic diverticulosis 5. gerd 6. acalculous cholecystitis s/p indwelling gallbladder catheter 7. obstructive lung disease? 8. low back pain social history: no current tobacco use. 60+ pack-year history. past heavy drinker. lives alone, son lives upstairs from him. family history: no family history of sudden cardiac death or early coronary artery disease. physical exam: physical exam: vs: t 97.3, bp 104/54 (99-120/41-58), hr 80 (76-90), o2sat 96% on ra rr 17. in 1030/out 3476 net 2446 (los negative 2837ml) gen: tired appearing male with eyes closed but awakens to answer questions appropriately heent: ncat, dry mm, clear op, perrl, eomi, anicteric sclera, non-injected conjunctiva. neck: elevated jvp to edge of jaw cv: difficult to hear secondary to upper airway secretions, but rrr, could not appreciate m/r/g chest: clear bilaterally without w/r/r with mild crackles at r base. anterior breath sounds obscured with upper airway secretion noises. abd: soft, nt, nd, bs+. ext: 2+ ble, very dry skin. pertinent results: [**2183-1-5**] 06:30pm blood wbc-9.0 rbc-3.83* hgb-10.8* hct-34.7* mcv-91 mch-28.3 mchc-31.2 rdw-15.6* plt ct-217 [**2183-1-7**] 03:05am blood wbc-4.7 rbc-3.29* hgb-9.3* hct-28.5* mcv-87 mch-28.3 mchc-32.6 rdw-15.7* plt ct-167 [**2183-1-7**] 10:47am blood wbc-5.5 rbc-3.50* hgb-10.1* hct-30.4* mcv-87 mch-28.8 mchc-33.1 rdw-15.9* plt ct-171 [**2183-1-10**] 06:07am blood wbc-3.6* rbc-3.13* hgb-8.8* hct-27.3* mcv-87 mch-28.1 mchc-32.2 rdw-15.5 plt ct-164 [**2183-1-11**] 06:23am blood wbc-3.0* rbc-2.96* hgb-8.1* hct-25.8* mcv-87 mch-27.4 mchc-31.4 rdw-15.4 plt ct-129* [**2183-1-11**] 09:14am blood hct-31.0* [**2183-1-5**] 06:30pm blood pt-14.1* ptt-27.1 inr(pt)-1.2* [**2183-1-6**] 02:14am blood pt-12.7 ptt-20.7* inr(pt)-1.1 [**2183-1-11**] 06:23am blood pt-13.1 ptt-31.3 inr(pt)-1.1 [**2183-1-11**] 06:23am blood ret aut-2.1 [**2183-1-5**] 06:30pm blood fibrino-509* [**2183-1-11**] 06:23am blood caltibc-316 hapto-207* ferritn-79 trf-243 [**2183-1-5**] 06:30pm blood glucose-207* urean-30* creat-2.5* na-141 k-5.8* cl-105 hco3-20* angap-22* [**2183-1-5**] 09:35pm blood glucose-192* urean-31* creat-2.5* na-142 k-4.5 cl-106 hco3-22 angap-19 [**2183-1-8**] 06:00am blood glucose-122* urean-44* creat-2.9* na-138 k-3.8 cl-104 hco3-24 angap-14 [**2183-1-11**] 06:23am blood glucose-129* urean-32* creat-2.6* na-142 k-4.1 cl-101 hco3-28 angap-17 [**2183-1-5**] 06:30pm blood ck(cpk)-146 amylase-102* [**2183-1-6**] 02:14am blood ck(cpk)-188* [**2183-1-6**] 10:03am blood ck(cpk)-207* [**2183-1-6**] 04:02pm blood ck(cpk)-194* [**2183-1-9**] 05:26am blood ck(cpk)-89 [**2183-1-11**] 06:23am blood ld(ldh)-247 totbili-0.4 [**2183-1-5**] 06:30pm blood ck-mb-4 ctropnt-0.03* [**2183-1-6**] 02:14am blood ck-mb-13* mb indx-6.9* ctropnt-0.20* probnp-8368* [**2183-1-6**] 10:03am blood ck-mb-11* mb indx-5.3 ctropnt-0.24* probnp-9154* [**2183-1-7**] 10:47am blood ck-mb-4 ctropnt-0.21* [**2183-1-5**] 09:35pm blood calcium-9.3 phos-5.4*# mg-2.3 [**2183-1-6**] 02:14am blood calcium-9.6 phos-4.4 mg-2.4 [**2183-1-11**] 06:23am blood calcium-9.4 phos-4.2 mg-2.2 iron-37* notable labs: 143 104 35 133 -------------< 3.6 25 2.6* (elevated from baseline 1.8) ck: 194 mb: 7 trop-t: 0.25 * ([**2183-1-6**] 10am: ck: 207 mb: 11 mbi: 5.3 trop-t: 0.24 [**2183-1-5**] 2am: ck: 188 mb: 13 mbi: 6.9 trop-t: 0.20) ca: 9.3 mg: 2.1 p: 3.4 probnp: 9154 wbc 5.5 hgb 11.5 hct 34.4 plt 172 mcv 88 pt: 12.7 ptt: 20.7 inr: 1.1 ekg: rate 100bpm, rhythm, axis lad, rbbb, st depressions at v2-v3 new but st depressions in v4-6 appear chronic. studies: [**2183-1-5**] cxr: cardiomegaly and moderate chf [**2183-1-6**]: no more fluid overload. ett tube in place . echo [**2183-1-6**]: the left atrium is moderately dilated. the estimated right atrial pressure is 0-5 mmhg. left ventricular wall thicknesses are normal. the left ventricular cavity is moderately dilated. there is severe global left ventricular hypokinesis with best preserved motion in the anteroseptum (lvef = 25 %). [intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size is normal. with mild global free wall hypokinesis. there are three aortic valve leaflets. the aortic valve leaflets are moderately thickened. there is mild aortic valve stenosis (area 1.6 cm2). mild to moderate ([**12-11**]+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. [due to acoustic shadowing, the severity of mitral regurgitation may be significantly underestimated.] there is borderline pulmonary artery systolic hypertension. mild pulmonic regurgitation is seen. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of [**2182-9-27**], regional left ventricular dysfunction now extends to the anterior and anterolateral walls. the overall ejection fraction is likely decreased. the severity of aortic regurgitation may have increased slightly. [**2183-1-8**] cardiac cath: final diagnosis: 1. three vessel coronary artery disease. 2. patent lima-lad 3. stenting of ostial and mid rca with des and poba to ostial pda. [**2183-1-8**] ecg: sinus rhythm ventricular premature complex marked left axis deviation left atrial abnormality rbbb with left anterior fascicular block since previous tracing of the same date, no significant change brief hospital course: 75 year old male with history of cad s/p cabgx3 and multiple pci's, chf with ef 30%, diastolic and systolic hf, cri, htn, now presenting with sob likely [**1-11**] chf. pt was intubated in ed and sent to the micu. he was extubated the following day and transferred out to the cardiology floor. # respiratory distress: respiratory distress likely combination of copd and chf, but more chf given bilateral lower exttremity edema, cxr finding of fluid overload, and overload on exam initially. mr. [**known lastname 63208**] has a known lvef of 25% based on echo here. patient was intubated in the ed and transferred to the micu. he was much improved the following day and was extubated successfully. he was treated with iv furosemide during this time. he was transferred to the cardiology service and was placed on a lasix drip for further diuresis. given his new onset worsening left ventricular function, he was sent for cardiac cath which was significant for 3vd and is now s/p stenting of ostial and mid rca with des and poba to ostial pda. #chf: systolic acute on chronic chf exacerbation as above. patient was to continue carvedilol 12.5 mg [**hospital1 **], isosorbide dinitrate 20mg tid. furosemide was incresed to 80mg [**hospital1 **] . #cad: cabg x 3 in [**2167**] (lima-lad, svg-om, svg-pda) with only lima-lad patent multiple pci's and multiple stents placed. patient has tropopin leak up to 0.25 up from 0.03. this was thought to be due to demand ischemia as ck levels were not elevated. patient was sent for cardiac cath as above. he is to continue home regimen of clopidogrel 75mg daily, asa 325mg daily, simvastatin 80mg daily, isosorbide dinitrate 20mg tid. pt started on carvedilol 12.5 mg [**hospital1 **]. # rhythm: atrial fibrillation: pt not anticoagulated [**1-11**] massive gi bleed; rate controlled only with nondihydropyridine nifedipine at home. switched to carvedilol this admission per cardiology. patient was monitored for bronchospasm given hx of copd. he did not have any adverse reaction and was discharged on carvedilol for management of his a-fib and chf. # copd: pt has known obstructive lung disease [**1-11**] extensive smoking history. he is to continue on his home combivent. . # cri: baseline cr (1.7-2.2), now elevated to 2.6 and remained there upon discharge. ace-i was held and will be restarted by dr. [**first name (stitle) 437**] in clinic if kidney function improves. . # htn: patient is to continue carvedilol, isosorbide dinitrate, amlodipine # diabetes mellitus: cont home glipizide . # dyslipidemia: continued simvastatin 80 daily. # phase 4 paroxysmal av block: patient has been seen by dr. [**last name (stitle) **] regarding icd/pm placement. this should be follow up by his pcp. medications on admission: medications on admission: ([**first name8 (namepattern2) **] [**doctor last name **] [**2182-12-16**] omr note): nifedipine 60 mg--one tablet by mouth once a day aspirin 325mg--take one by mouth every day amlodipine 5 mg--one tablet by mouth once a day clopidogrel bisulfate 75mg--one by mouth every day combivent 103-18 mcg/actuation--take 2 puffs three times a day as needed for wheezing furosemide 20 mg--three tablets by mouth once a day glipizide 5 mg--take 1 tablet(s) by mouth once a day 1 hour after a meal isosorbide dinitrate 20 mg--one tablet by mouth three times a day nitroglycerin 400 mcg (1/150 gr)--take as directed as needed for chest pain protonix 40 mg--take 1 tablet(s) by mouth once a day (20 minutes before a meal) roxicet 5 mg-325 mg--take 1 tablet(s) by mouth four times a day as needed for pain (twenty-eight day supply) simvastatin 80 mg--take 1 tablet(s) by mouth at bedtime ***** pt does not appear to be on lisinopril per pcp [**2182-12-16**] note, although he was discharged on lisinopril after his last hospital admission. ***** discharge medications: 1. simvastatin 40 mg tablet sig: two (2) tablet po daily (daily). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 3. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 4. isosorbide dinitrate 10 mg tablet sig: two (2) tablet po tid (3 times a day). 5. carvedilol 12.5 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 6. petrolatum ointment sig: one (1) appl topical tid (3 times a day) as needed. disp:*1 tube* refills:*2* 7. glipizide 5 mg tablet sig: one (1) tablet po once a day: 1 hour after a meal. 8. combivent 18-103 mcg/actuation aerosol sig: two (2) puffs inhalation tid prn as needed for shortness of breath or wheezing. 9. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 10. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) sublingual q5min prn as needed for chest pain: one tablet every 5min for a total of 3 doses if needed for chest pain. 11. nifedipine 60 mg tablet sustained release sig: one (1) tablet sustained release po once a day. 12. amlodipine 5 mg tablet sig: one (1) tablet po once a day. 13. roxicet 5-325 mg tablet sig: one (1) tablet po qid prn as needed for pain. 14. furosemide 80 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*2* discharge disposition: home with service facility: [**location (un) 86**] vna discharge diagnosis: primary: systolic heart failure exacerbation coronary artery disease s/p pci with des to rca and poba to pda secondary: - coronary artery disease - atrial fibrillation, not anticoagulated due to massive gi bleed [**2176**] - pvd with b fem to distal bypass - hypertension - hypercholesterolemia - copd - dm2 - gerd - chronic renal insufficiency baseline 1.5 - 2.0 discharge condition: stable discharge instructions: you were admitted into [**hospital1 69**] for treatment of your congestive heart failure. you were in severe respiratory distress on arrival and you were intubated and placed on a breathing machine for 24 hours. your heart failure has been treated successfully with intravenous diuretics. an ultrasound of the heart was done which showed worsening heart function. a cardiac catheterization was done to evaluate your arteries. you had a new occlusion of your right coronary artery which was opened with a drug eluting stent. a balloon was also used to open up a second artery. please stop taking your lisinopril for the time being. your kidney function has slightly worsened with the diuresis and you should not take your lisinopril as it may contribute to worsening kidney function. your kidney function will be reevaluated by dr. [**first name (stitle) 437**] at your visit with him. your lasix has been increased from lasix 60mg daily to lasix 80mg twice per day. please continue with your remaining regular home medications. please attend recommended follow up below. if you experience worsening chest pain, shortness of breath, palpitations, nausea, vomiting, increased leg swelling, dizziness, lightheadedness, fainting or any other concerning symptoms then please call your doctor or report to the nearest emergency room. weigh yourself every morning, [**name8 (md) 138**] md if weight > 3 lbs. adhere to 2 gm sodium diet followup instructions: please call your new cardiologist, dr. [**first name (stitle) 437**] at [**telephone/fax (1) 3512**] to set up an appointment to be seen on [**2183-1-23**]. provider: [**first name11 (name pattern1) **] [**last name (namepattern4) 5377**], md phone:[**telephone/fax (1) 250**] date/time:[**2183-1-22**] 8:20 provider: [**first name11 (name pattern1) **] [**last name (namepattern4) 5377**], md phone:[**telephone/fax (1) 250**] date/time:[**2183-3-5**] 8:20",0
120,"admission date: [**2115-9-6**] discharge date: [**2115-9-10**] date of birth: [**2051-7-18**] sex: f service: medicine allergies: no known allergies / adverse drug reactions attending:[**first name3 (lf) 4095**] chief complaint: melena major surgical or invasive procedure: egd [**2115-9-6**] and [**2115-9-9**] colonoscopy [**2115-9-9**] history of present illness: 64f w/pmhx paf on pradaxa (history of l mca stroke, poor compliance with coumadin, ~20% stroke risk), p/w melena x 3d and some epigastric discomfort. pt reports that she has had mild epigastric burning sensation, accompanied by black stools. she reports that she is moving her bowels ~3x daily, but that there is no diarrhea or large volume stools. she went to her pcps office who noted that she was orthostatic 117-->90 and dizzy and had melena on exam and she was sent to the ed. she was seen in clinic on [**9-6**], when she was noted to have bp of 90/60 with dizziness. black heme positive stool was noted in the rectal vault. she was subsequently sent to the ed for evaluation. in ed, bp 102/58, p 74. pt had scant black stool on exam. she was typed and crossed for 2 units of blood, and started on a protonix gtt. in the ed her initial vital signs were: 98.0 74 102/58 14 98% ra. exam was notable for melena per rectum, abdominal exam was benign. hct was 28 with most recent in our system of 45. she did not tolerate ng tube so no lavage was performed. she was type and crossed for 2u prbc and started on a ppi bolus and drip. she was otherwise stable and transferred to the micu for furhter management of her ugib in the setting of anticoagulation with praxada. on arrival to the micu the patient has no complaints. she reports that she had 3 days of melena. has no history of gi bleeds, no history of ulcers, and no recent nsaid use or aspirin use. she denies any smoking or alcohol use. she reports decreased po intake over the past day and a half due to no appetitie but denies nausea or vomiting. no abdominal pain, no diarrhea. of note her last colonoscopy was in [**2108**] and showed diverticula. on arrival to the floor, patient had stable hct and vitals. she denied any bloody stools, hematochezia, hematemesis, hemoptysis, dizziness/lightheadedness, fevers/chills, n/v/d, abdominal pain. she stated that she felt well and wanted to go home. past medical history: -hypercholesterolemia -paroxysmal atrial fibrillation -right shoulder pain [**2099**] -secondary amenorrhea [**2089**] -thromboembolic stroke- cardiac embolus to l mca territory in [**2113**] while on aspirin. has been on pradaxa since then. -cardiac cath [**2110**]- normocoronaries social history: 1ppd until [**2113**] when she quit no drugs no alcohol use brother recently passed away works at [**hospital1 2177**] as a circulating nurse . family history: brother has history of ulcers, liver cirrhosis, and alcoholism. mom had afib, esrd, and adverse reaction to coumadin physical exam: admission physical exam general: alert, oriented, no acute distress, pale appearing heent: sclera anicteric, conjunctival pallor, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: rrr< no mrg appreciated lungs: ctab, moving good air bilaterally abdomen: soft, minimally tender to palpation in the epigastrium, non-distended, bowel sounds present, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact discharge physical exam vitals t: 97, bp: 112/70, hr: 58, rr: 16, sat: 99% ra general: nad, comfortable heent: mmm, decreased hearing to l ear neck: supple, no jvd appreciated, no ld cv: rrr, no m/g/r lungs: ctab, no crackles/wheezes/rhonchi, unlabored respirations abdomen: soft, nt, nd, +bs, no guarding/rebound ext: wwp, 2+ pt pulses, no edema neuro: a&ox3, moving all extremities, normal gait pertinent results: admission labs [**2115-9-6**] 10:08am blood wbc-9.1 rbc-3.27*# hgb-9.8*# hct-29.2*# mcv-89 mch-29.9 mchc-33.5 rdw-13.7 plt ct-272 [**2115-9-6**] 10:08am blood neuts-75.1* lymphs-18.9 monos-4.9 eos-0.5 baso-0.6 [**2115-9-6**] 10:08am blood pt-14.1* ptt-44.2* inr(pt)-1.3* [**2115-9-6**] 10:08am blood glucose-131* urean-51* creat-1.0 na-140 k-3.8 cl-105 hco3-27 angap-12 [**2115-9-6**] 10:08am blood albumin-3.8 calcium-9.1 phos-3.4 mg-1.9 [**2115-9-6**] 03:17pm blood hct-27.5* [**2115-9-6**] 09:31pm blood hct-25.7* [**2115-9-7**] 02:42am blood wbc-7.5 rbc-3.04* hgb-9.1* hct-26.9* mcv-89 mch-30.1 mchc-34.0 rdw-13.9 plt ct-207 [**2115-9-7**] 11:57am blood hct-27.6* discharge labs: [**2115-9-10**] 06:35am blood wbc-5.0 rbc-3.30* hgb-9.8* hct-29.8* mcv-90 mch-29.7 mchc-33.0 rdw-14.4 plt ct-291 [**2115-9-10**] 06:35am blood glucose-116* urean-10 creat-1.0 na-140 k-4.0 cl-105 hco3-25 angap-14 [**2115-9-10**] 06:35am blood calcium-8.7 phos-3.8 mg-2.1 urine [**2115-9-6**] 10:08am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-sm [**2115-9-6**] 10:08am urine rbc-<1 wbc-2 bacteri-few yeast-none epi-13 transe-1 imaging ct abdomen [**2115-9-7**]: no extraluminal contrast or findings to suggest enterobiliary fistula. egd [**2115-9-6**]: -abnormal mucosa in the stomach -abnormal mucosa in the stomach -mild erythema in duodenal bulb -in the second portion of the duodenum, a large diverticulum was noted. within this diverticulum, there was a black/green mass that had the appearance of a large gallstone. this was adherent to the mucosa. attempts were made to dislodge the mass with flushing and gentle advancement of the endoscope without success. a portion of this material was removed via rothnet for pathological analysis. clinical appearance was suggestive of gallstone ileus versus erosion of gallbladder into duodenum. a portion of this material was removed via [**doctor last name **] net [**2115-9-6**] pathology: consistent with a mixed-type calculus; examined grossly and microscopically. egd [**2115-9-9**] angioectasia in the duodenal bulb (thermal therapy) diverticulum in the second part of the duodenum small hiatal hernia colonoscopy [**2115-9-9**] multiple diverticula were seen in the sigmoid colon and distal descending colon. impression: diverticulosis of the sigmoid colon and distal descending colon recommendations: in hospital care. capsule endoscopy. brief hospital course: ms. [**known lastname **] is a 64 yo f w/ pmh of paroxysmal atrial fibrillation complicated by a left mca thromboembolic stroke without any residual deficits who was anticoagulated with pradaxa and presented to her pcps office with melena x 3days and found to have a duodenal diverticula with mass that appeared to be a gallstone. #upper gi bleed- patient presented with melena and hct drop from 45-->29.2 (from 2 years prior) and orthostatic. this was in the setting of being on pradaxa and had no known preciptants of nsaids, alcohol, or smoking. she was admitted to the icu for urgent egd and monitoring given her need for continued anticoagulation. egd showed no ulcers or gastritis and there was a divericula in the 2nd part of the duodenum with a green/black mass that appeared to be a gallstone and was biopsied. pathology showed a mixed-type calculus. she was transfused 1u prbc with inappropriate bump in hct and was monitored in the icu prior to being transfered to the floor. when patient was transferred to the floor, she had stable vital signs and hematocrit. she reported that her stools were non-bloody and looked brown. she underwent a repeat egd and a colonoscopy. the egd showed a single small angioectasia that was not bleeding in the duodenal bulb. a gold probe was applied for tissue destruction successfully. a single non-bleeding diverticulum with large opening was found in the second part of the duodenum. a small hiatal hernia was also seen. the colonoscopy showed diverticulosis of the sigmoid colon and distal descending colon. since no source of the gi bleeding was identified a capsule study was recommended, which the patient had the following day. she tolerated the capsule study without any problems. [**name (ni) **] hematocrit remained stable at around 27-29 throughout the rest of her hospitalization. on discharge, she felt well and denied any bloody stools or melena. she was discharged with a ppi. #paroxysmal afib- patient has been on pradaxa prior to admission. she has a history of paroxysmal afib with a subsequent stroke while on aspirin. her chads2 score is only a 2, however given it was for a stroke she requires lifelong anticoagulation. on admission, her pradaxa was discontinued and she was started on a heparin drip as a bridge after her egd was performed to reduce her risk of stroke. her pradaxa was discontinued in the meantime. based on discussions with her cardiologist, dr. [**last name (stitle) **], it was recommended to start coumadin and discontinue pradaxa. given her risk of bleeding, patient should be on an anticoagulant that can be closely monitored and reversed to prevent future gi bleed especially since the source of bleeding could not be identified by egd and colonoscopy. this was fully explained to ms. [**known lastname **]. there were several discussions with the patient regarding the risk of bleeding by restarting pradaxa and our recommendation of starting coumadin. however, patient's mother had an adverse reaction to coumadin and she refused to start coumadin, thinking that she will definitely have the same reaction. we attempted to reassure the patient several times that adverse side effects are rare and that she will be closely monitored while on coumadin, but she continued to refuse the medication. given her ugib in the setting of pradaxa and her continuous refusal to start coumadin, dr. [**last name (stitle) **] recommended restarting on pradaxa at a lower dose (from 150mg to 75mg [**hospital1 **]). the risk of a stroke at this lower dose was explained to the patient. she acknowledged full understanding of the risks of continuing with pradaxa (increased risk of bleeding if she returns to her previous dose and increased risk of stroke at the lower dose). she also acknowledged understanding of why we thought coumadin was a better choice -- a decreased risk of both bleeding and having a stroke while on the appropriate dose of coumadin. she believed that the potential adverse reaction of coumadin outweigh the benefits. therefore, she was discharged with 75mg pradaxa and bridged with lovenox. she will follow up with her cardiologist, dr. [**last name (stitle) **], in one month. #hyperlipidemia -continued on home simvastatin # transitional issues []results of capsule study. gi will call patient with the results of the capsule study and will arrange appropriate follow up. []after several discussions with the patient, also involving her cardiologists, patient refused to start coumadin. she was thus restarted on pradaxa but at a lower dose (75mg) to prevent future gi bleed. medications on admission: preadmission medications listed are correct and complete. information was obtained from patientwebomr. 1. dabigatran etexilate 150 mg po bid 2. metoprolol tartrate 25 mg po tid 3. propafenone *nf* 325 mg oral [**hospital1 **] extended release 4. simvastatin 40 mg po daily discharge medications: 1. metoprolol tartrate 25 mg po tid 2. simvastatin 40 mg po daily 3. propafenone *nf* 325 mg oral [**hospital1 **] extended release 4. dabigatran etexilate 75 mg po bid rx *pradaxa 75 mg 1 capsule(s) by mouth twice a day disp #*60 tablet refills:*0 5. pantoprazole 40 mg po q12h rx *pantoprazole 40 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*0 discharge disposition: home discharge diagnosis: primary diagnosis: upper gi bleeding secondary diagnosis: afib, hypercholesterolemia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. [**known lastname **], it was a pleasure taking care of you during your hospitalization at [**hospital1 69**]. you were admitted because you had black stools that was positive for blood. your blood count also decreased due to a bleeding in your intestinal tract and you needed a transfusion. you had an endoscopy and colonoscopy that showed a single small angioectasia that was not bleeding and was treated with thermal therapy. you also had a capsule study to help identify the source of the bleeding. the results of the capsule study will take about 8 days. please follow up with the gastroenterologist for the results of your capsule study. you should avoid nsaids and aspirin because they can increase your risk of bleeding. you can restart taking pradaxa (but at a lower dose) twice a day to prevent clots. followup instructions: the gastroenterologist will call you with the results of your capsule study. you should also call [**telephone/fax (1) 463**] to set up an appointment with a gastroenterologist. you should follow up with your cardiologist, dr. [**last name (stitle) **] in one month. his office will call you with the details of the time and date of the appointment. you should also call your primary care physician, [**last name (namepattern4) **]. [**last name (stitle) **], to set up an appointment. completed by:[**2115-9-12**]",1
121,"admission date: [**2141-12-25**] discharge date: [**2142-1-1**] date of birth: [**2118-7-26**] sex: m service: neurosurgery history of present illness: the patient is a 23 year old gentleman who jumped from a five story building, hit a tree branch on the way down and landed in the snow. the fall was unwitnessed. there was question of loss of consciousness. the patient was found by paramedics confused with [**initials (namepattern4) **] [**last name (namepattern4) 2611**] coma score of 14. friends reported that he might have been using mushroom. past medical history: orthostatic hypotension. allergies: the patient has no known drug allergies. physical examination: on physical examination, the patient had a temperature of 97.5, heart rate 83, blood pressure 166/83, respiratory rate 22 and oxygen saturation 100% with [**initials (namepattern4) **] [**last name (namepattern4) 2611**] coma score of 14. the patient was oriented to person, following simple commands, agitated and restless, perseverating on his name. he had a 4 cm laceration through the right eyelid. pupils equal, round, and reactive to light. abrasions on right cheek. face stable. trachea midline. no crepitus. lungs clear and equal bilaterally. cardiovascular: regular rate and rhythm. abdomen: soft, nontender, nondistended, abrasion over right upper quadrant and right flank. pelvis stable. 5/5 strength in all four extremities. palpable femoral and dorsalis pedis pulses bilaterally. bilateral knees with ecchymoses and edema. rectal guaiac negative. laboratory data: admission white blood cell count 14, hematocrit 44.3, platelet count 317,000, sodium 142,potassium 3.7, chloride 99, bicarbonate 26, bun 17, creatinine 1.1, glucose 150, lactate 3.7, amylase 76, fibrinogen 180. urinalysis: positive for large amount of blood. serum toxicology screen: negative. urine toxicology screen: negative. chest x-ray: negative. head ct scan: right subdural hematoma, posterior, and a small intraparenchymal hemorrhage on the left and some cerebral edema. cervical spine: negative for fracture. flexion/extension films: negative; patient was removed from a hard collar. lumbar/thoracic: l1 burst fracture. hospital course: the patient was admitted and monitored in the trauma surgical intensive care unit. he was seen by the plastic surgery service, who repaired his laceration over his left eye. he was intubated on arrival. he was extubated on [**2141-12-26**]. he was seen by the psychiatry service. the patient was evaluated for attempted suicide. it was felt that this incident was not a suicide attempt but rather a result of mushroom ingestion. the patient remained neurologically stable. he was fitted for a tlso brace. on [**2140-12-28**], he received his tlso brace and was transferred to the regular floor. he was seen by physical therapy and occupational therapy. he continued to be followed by psychiatry because he became extremely agitated and delirious. they decided at that point that it was likely due to narcotics, he had had an adverse reaction to narcotics in the past. narcotics were discontinued and the patient was given tylenol for back pain and headache pain. the patient continued to be evaluated and followed by physical therapy, who felt that he would require rehabilitation prior to discharge to home. his delirium cleared and he was removed from one-to-one sitters. discharge medications: colace 100 mg p.o.b.i.d. dilantin 150 mg p.o.q.8h. haldol 2 mg p.o.b.i.d. bacitracin ointment one application topically t.i.d. neomycin and bacitracin ophthalmologic ointment one application q.i.d. tramadol 50 mg p.o.q.4h.p.r.n. tylenol 1 gm p.o.q.6h. protonix 40 mg p.o.q.24h. artificial tears one to two drops o.u.p.r.n. lacri-lube ointment one application o.u.p.r.n. condition on discharge: stable. discharge instructions: the patient should place his brace on the lying position and should be wearing it at all times when out of bed. follow-up: the patient was instructed to follow up with dr. [**last name (stitle) 1327**] in two weeks' time with repeat x-rays and head ct scan. [**name6 (md) 1339**] [**last name (namepattern4) 1340**], m.d. [**md number(1) 1341**] dictated by:[**last name (namepattern1) 344**] medquist36 d: [**2142-1-1**] 12:00 t: [**2142-1-1**] 13:31 job#: [**job number **]",1
122,"admission date: [**2130-9-23**] discharge date: [**2130-9-28**] date of birth: [**2082-12-1**] sex: m service: medicine allergies: penicillins / vancomycin / acyclovir attending:[**first name3 (lf) 9874**] chief complaint: blurry vision bilaterally major surgical or invasive procedure: picc line placement. lumbar puncture. history of present illness: 47 yo m with a history of hiv (last cd4 ([**1-1**]) 81, vl 48) who restarted haart 3 weeks ago who presented to the ed from [**hospital 18620**] clinic with a complaint of worsening vision loss. his symptoms started in mid-[**month (only) 205**], when he suddenly developed some mild pain at the back of his left eye. his left eye then started to produce tear-like clear fluid. the vision in his left eye started to deteriorate over the course of the next week. his left eye had blurry vision, he had floaters in front of his eyes, and he noted central vision loss. he denied headache. these symptoms prompted him to present to his pcp and ophthalmologist, and he was prescribed predforte drops q1 h and scopolamine drops [**hospital1 **], which initially provided relief of the symptoms. however, in [**month (only) 216**], he developed similar symptoms in his right eye (pain, central vision loss, blurry vision) and he saw his ophthamologist again. he continued to use the eye drops in both eyes, but he still intermittently had blurry vision. during the week prior to admission, he started to experience exacerbation of his visual changes, and he may not have been compliant with using the eye drops. he reports the vision loss is worse in his left eye, and he can only see shadows. . he was seen by ophthalmology on the day prior to admission, and was diagnosed with bilateral panuveitis. ophtho recommended that he be admitted for further workup. . of note, per logician notes, he was recently informed by the doh that he had sexual contact with a person who was diagnosed with syphilis. past medical history: 1.hiv, diagnosed in [**2118**]. but possibly acquired the infection in [**2108**]. he didn't take any anti-retroviral drugs for 4 years, but restarted 3 weeks ago. (last cd4: 81 cell/ul ([**2130-1-19**]); last viral load 48.01*hi ([**2130-1-19**]) 2.shingles [**2118**], no more incidence ever since 3.left meniscus tear s/p knee surgery 4.arthritis, especially of knees b/l 5.hyperlipidemia [**3-/2123**] 6.acute gingivitis [**5-/2123**] 7.viral warts [**2119**] 8.nonspecific skin rash [**4-/2123**] 9.cryptosporidiosis [**8-/2123**] 10.pityriasis versicolor [**10/2123**] 11.hepatitis a [**3-/2123**] 12.oral aphthae 13.depression 14. deviated septum . allergies: penicillin causes itchy hives and rash (received pcn once as child and once in 20s-30s), vancomycin (red man syndrome), acyclovir (itchiness), seasonal allergies social history: 10 pack-year smoking history, quit 15 years ago. social etoh use. recreational illicit drug use in the past, but has not been using drugs during the past several years. works part-time at mistral restaurant as a server; also started to work as a photographer, had a photography show recently. family history: dm (mother), colon ca (father, at 88 [**name2 (ni) **]), kidney problems, stroke, htn, gi problems. physical exam: vs: temp 99.8, bp 120/60, hr 89, rr 20, sao2 100% ra general: awake, alert, nad heent: ncat. mmm. op clear, no oral thrush. sclera anicteric. no supraclavicular, submandibular, or anterior cervical lad. patchy alopecia of hair and beard. cv: regular rate, nl s1, s2. no murmurs/rubs/gallops. pulm: cta bilaterally. no wheezes/rhonchi/rales abd: positive bowel sounds, soft ntnd abdomen. no hsm. no masses ext: no lower extremity edema skin: no rashes neuro: pupils dilated to 6 mm bilaterally, not reactive to light. patient unable to cross eyes to check for accomodation. patient could count fingers at 1 foot. patient can not make out details in visitor's face at bedside. eomi. fundoscopic exam on r revealed normal vasculature, no obvious abnormalities of optic disc. unable to visualize fundus/vessels on the l. normal facial sensation and strength. tongue protrudes in midline. moving all extremities spontaneously. pertinent results: [**2130-9-28**] 04:55am blood wbc-4.1 rbc-3.92* hgb-11.3* hct-33.7* mcv-86 mch-28.8 mchc-33.5 rdw-18.2* plt ct-331 [**2130-9-24**] 11:55am blood pt-12.4 ptt-23.8 inr(pt)-1.1 [**2130-9-24**] 06:45am blood wbc-6.4 lymph-10* abs [**last name (un) **]-640 cd3%-73 abs cd3-467* cd4%-13 abs cd4-80* cd8%-56 abs cd8-358 cd4/cd8-0.2* [**2130-9-28**] 04:55am blood glucose-110* urean-13 creat-0.7 na-141 k-4.6 cl-104 hco3-28 angap-14 [**2130-9-26**] 06:12am blood calcium-8.6 phos-3.8 mg-2.5 [**2130-9-27**] 04:55am blood alt-13 ast-13 ld(ldh)-111 alkphos-93 amylase-87 totbili-0.1 [**2130-9-27**] 04:55am blood lipase-35 [**2130-9-27**] 04:55am blood albumin-3.3* iron-133 [**2130-9-27**] 04:55am blood caltibc-322 vitb12-324 folate-5.9 ferritn-218 trf-248 [**2130-9-27**] 04:55am blood ret aut-1.4 [**2130-9-24**] 06:45am blood osmolal-272* [**2130-9-25**] 08:15am urine hours-random urean-407 creat-48 na-43 [**2130-9-25**] 08:15am urine osmolal-308 [**2130-9-24**] 06:45am blood rheufac-<3 hiv-1 viral load/ultrasensitive (final [**2130-9-28**]): 1,390 copies/ml. blood tests: rpr reactive fta-abs reactive vzv ab igm, eia negative ace normal hla-b27 pending lyme by western blot: lyme disease ab, conf. igg western blot 1 band <5 igg bands detected 41 kda igm western blot 0 band <2 igm bands detected none detected kda interpretation -------------- nonconfirmatory lyme serology (final [**2130-9-28**]): eia result not confirmed by western blot. equivocal by eia. negative by western blot. varicella-zoster igg serology (final [**2130-9-26**]): positive by eia. cmv igg antibody (final [**2130-9-26**]): positive for cmv igg antibody by eia. 312 au/ml. reference range: negative < 4 au/ml, positive >= 6 au/ml. cmv igm antibody (final [**2130-9-26**]): negative for cmv igm antibody by eia. toxoplasma igg antibody (final [**2130-9-26**]): negative for toxoplasma igg antibody by eia. 0.0 iu/ml. reference range: negative < 4 iu/ml, positive >= 8 iu/ml. toxoplasma igm antibody (final [**2130-9-26**]): negative for toxoplasma igm antibody by eia. interpretation: no antibody detected. [**2130-9-24**] 6:45 am blood culture ( myco/f lytic bottle) blood/fungal culture (preliminary): no fungus isolated. blood/afb culture (preliminary): no mycobacteria isolated. [**2130-9-24**] blood culture: ngtd x2 csf studies: [**2130-9-24**] 3:41 pm csf;spinal fluid source: lp. added cryptococcal ag and mycology cx [**2130-9-25**] per add on requisition. gram stain (final [**2130-9-24**]): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final [**2130-9-27**]): no growth. viral culture (preliminary): no virus isolated so far. fungal culture (preliminary): no fungus isolated. cryptococcal antigen (final [**2130-9-25**]): cryptococcal antigen not detected. (reference range-negative). performed by latex agglutination. results should be evaluated in light of culture results and clinical presentation. acid fast culture (preliminary): the sensitivity of an afb smear on csf is very low.. if present, afb may take 3-8 weeks to grow.. analysis wbc rbc polys lymphs monos [**2130-9-24**] 03:41pm 190 5 72 24 4 2 clear and colorless [**2130-9-24**] 03:41pm 110 400 47 42 11 source: lp 2 clear and colorless chemistry totprot glucose [**2130-9-24**] 03:41pm 113 29 vdrl pending treponema antibody pending herpes simplex virus [**12-27**] detection and diff, pcr hsv 1 dna not detected hsv 2 dna not detected [**doctor last name **]-[**doctor last name **] virus (ebv) dna, pcr result: detected studies: ct head ([**9-23**]): impression: no evidence of intracranial mass or hemorrhage. cxr ([**9-23**]): impression: no acute cardiopulmonary process. brief hospital course: 47 yo male with hiv and recently diagnosed bilateral panuveitis who presents from ophthalmology clinic with worsening vision loss. . #vision loss: the patient was admitted with bilateral vision loss, central scotoma, and a recent exposure to syphilis. infectious disease was consulted, and followed him throughout his hospitalization. he was afebrile during the admission without an elevated wbc. he was initially empirically started on vancomycin 1 gm iv q12hr for possible staph uveitis and acyclovir 10 mg/kg iv q8hr for possible cmv/hsv infection. the patient developed diffuse urticaria and rash after receiving vancomycin, thought to be red man syndrome. his symptoms improved with premedication with diphenhydramine prn and ranitidine [**hospital1 **]. mri of the orbits was unable to be completed secondary to the patient's claustrophobia. head ct showed no evidence of intracranial mass or hemorrhage. lp showed opening pressure of 8, elevated wbc, increased protein, decreased glucose. csf showed no bacteria, no virus isolated so far, no fungus, and no cryptococcal antigen. the csf was negative for hsv 1 and 2 but positive for ebv. csf vdrl and treponema antibody were pending at the time of discharge. serum rpr was reactive, pending confirmation from the state. serum fta-abs was reactive. the patient was thought to have neuro-ocular syphilis and was started on penicillin g 4,000,000 units iv q4 hours after pcn desensitization in the micu. vancomycin was discontinued on hospital day 3 as staph uveitis was a less likely diagnosis. acyclovir was discontinued on hospital day 5 when csf viral culture showed no virus isolated so far. a picc line was placed on [**9-27**], and the patient was sent home with an infusion pump for penicillin g 4,000,000 u iv q4 hours for 14 day course (last day [**2130-10-9**]). he was sent home with an epinephrine pen in case he develops an anaphylactic reaction. the patient will have follow up with id, ophthamology, and his pcp. [**name initial (nameis) **] the patient may need an mri brain as an outpatient to look for lymphoma as his csf was positive for ebv. - other positive blood tests: vzv igg, cmv igg - other negative blood tests: vzv ab igm, cmv igm, toxoplasma igg/igm, lyme disease, blood/fungal culture, blood/afb culture, ace, rf <3, ppd negative - pending blood tests: blood cx x2 ngtd, hla-b27 - pending csf tests: afb cx, vdrl, treponema antibody . #penicillin allergy: the patient reported a history of non-anaphylactic allergy to pcn, and had developed hives and a rash after receiving it once as a child and once in his 20s-30s. the patient's vision loss was due to neurosyphilis, and pcn-g iv is the recommended treatment. the patient was transferred to the micu for pcn desensitization protocol, with 7 doses of increasing penicillin over 3 hours. the patient did not have any adverse reactions. if patient's pcn doses are separated by greater than 12 hours, he will need repeat desensitization. . #bilateral panuveitis: the patient was seen in [**hospital 18620**] clinic on the day prior to admission and was found to have os synechiae/irregular pupil and no evidence of retinitis ou. per their report, he had bilateral panuveitis and vision loss threatening ou. they recommended for him to continue pred forte 1 gtt q1hr ou and scopolamine 0.25% 1 gtt [**hospital1 **] ou, which had been prescribed to him a few months earlier. these drops were continued during his hospitalization. ophthamology followed him during his hospital stay, and he will follow up with them as an outpatient. . # hiv: the patient was diagnosed with hiv in [**2118**] [last cd4 ([**1-1**]) 81, vl 48]. he stopped taking antiretroviral medications 4 years ago, but was restarted on haart 3 weeks prior to admission. his outpatient antiretroviral regimen was continued during the hospitalization (darunavir, emtricitabine-tenofovir, ritonavir, and zidovudine). he also was continued on bactrim ds daily for pcp [**name initial (pre) 1102**]. the patient had a cd4 count of 80 and cd4% of 13, and his hiv viral load was 1,390 copies/ml. a cxr showed no acute cardiopulmonary process. . #hyponatremia: the patient presented with a na of 134, which decreased to 131 on day 2 of admission. serum osm 272, urine osm 308, urine urea 407, urinecr 48, urinena 43. the patient was thought to have siadh, and was started on a 1 l free water restriction. na improved to 141, and the patient was taken off of the free water restriction. . #anemia: hct upon admission was 37.9, but dropped to 31.1 on hospital day 2. the patient had guaiac negative stools, iron studies normal, normal reticulocyte count, and normal b12 and folate levels. his coags were all within normal limits. his hct improved to 33.7 at the time of discharge, and his anemia was possibly due to hemodilution from siadh. . #arthritis: the patient has chronic arthritis especially in his knees bilaterally. he can follow up with his pcp upon discharge. . # depression: the patient has been experiencing depressive symptoms intermittently. he was seen by social work while in the hospital, and was encouraged to follow up with his pcp upon discharge. medications on admission: 1.ritonovir 100mg po bid 2.truvada 200-300 mg po daily 3.retrovir 300mg q12h 4.prezista 600mg po bid 5.bactrim ds 800-160mg po daily 6.androgel pack 50mg/5gm po daily 7.predfort 1% 1 drop ou q1h 8.scopolamine 0.25% 1 drop ou [**hospital1 **] . allergies: penicillin discharge medications: 1. ritonavir 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 2. epinephrine hcl 0.1 mg/ml syringe sig: one (1) injection as needed as needed for anaphylaxis. disp:*1 syringe* refills:*2* 3. emtricitabine-tenofovir 200-300 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. zidovudine 100 mg capsule sig: three (3) capsule po q12h (every 12 hours). disp:*180 capsule(s)* refills:*2* 5. darunavir 300 mg tablet sig: two (2) tablet po bid (). disp:*120 tablet(s)* refills:*2* 6. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. testosterone 1 %(50 mg/5 gram) gel in packet sig: one (1) packet transdermal daily (). 8. prednisolone acetate 1 % drops, suspension sig: one (1) drop ophthalmic q1h (every hour): 1 drop to each eye every hour. disp:*1 bottle* refills:*2* 9. scopolamine hbr 0.25 % drops sig: one (1) drop ophthalmic [**hospital1 **] (2 times a day): 1 drop to each eye twice a day. disp:*1 bottle* refills:*2* 10. diphenhydramine hcl 12.5 mg/5 ml elixir sig: five (5) ml po q4-6h () as needed for allergic reaction, itchy, hives. disp:*1 bottle* refills:*2* 11. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day) for 12 days. disp:*24 tablet(s)* refills:*0* 12. penicillin g potassium 1,000,000 unit recon soln sig: [**numeric identifier 109457**] ([**numeric identifier 109457**]) units injection every four (4) hours for 12 days: end date [**2130-10-9**]. disp:*[**numeric identifier 109458**] units* refills:*0* 13. picc supplies picc line care per ccs protocol 14. outpatient lab work please draw cbc, bun, cr, lfts (ast, alt, alk phos, amylase, lipase, t bili, ldh) on [**10-4**]. these results should be faxed to [**first name4 (namepattern1) **] [**last name (namepattern1) 1075**] in [**hospital **] clinic at [**hospital3 **] ([**telephone/fax (1) 1419**]). discharge disposition: home with service facility: [**hospital 119**] homecare discharge diagnosis: primary: 1. bilateral panuveitis 2. neurosyphilis 3. hiv 4. penicillin allergy secondary: 1. depression 2. arthritis discharge condition: stable, vision improving. discharge instructions: 1. if you develop a fever >101.5, increased vision loss, severe headache, rash, shortness of breath, chest pain, or any other symptoms that concern you, contact your primary care physician or come to the emergency department. 2. take all of your medications as prescribed and on time. 3. attend all of your follow up appointments. followup instructions: you have an appointment on [**2130-10-5**] at 12:00 with dr. [**first name4 (namepattern1) **] [**last name (namepattern1) 571**] at [**hospital1 778**]. you have an appointment on [**2130-10-6**] at 8:45 with dr. [**first name (stitle) **] love ([**telephone/fax (1) 457**]) in infectious diseases at [**hospital unit name **], basement id west. you have an appointment on [**2130-10-27**] at 10:30 with dr. [**first name (stitle) **] love ([**telephone/fax (1) 457**]) in infectious disease at [**hospital unit name **], basement id west. you have an appointment with dr. [**last name (stitle) 441**] ([**telephone/fax (1) 253**]) in ophthamology on [**2130-10-19**] at 9:00 at [**hospital ward name 23**] center, floor 5. you will need a follow up mri brain done for ebv in your csf done in the outpatient setting, follow up about this with your primary care physician.",0
123,"admission date: [**2107-5-24**] discharge date: [**2107-5-31**] date of birth: [**2028-4-19**] sex: f service: neurosurgery allergies: penicillins / sulfa (sulfonamide antibiotics) / amiodarone / prilosec / spironolactone / epinephrine / shellfish derived / valium / lipitor / fish product derivatives / lidocaine / trimethoprim-polymyxin b / amiodarone / benadryl decongestant / iodine attending:[**first name3 (lf) 1835**] chief complaint: speech difficulty major surgical or invasive procedure: [**2107-5-26**] left parietal crani for tumor biopsy history of present illness: [**known firstname 1123**] [**known lastname 51820**] is a 79-year-old right-handed woman, with remote history of stage i breast cancer in the right breast, status post lumpectomy, and radiotherapy [**2092**], who presented to btc yesterday with dr. [**last name (stitle) 724**] for new finding of left parietal mass on workup for speech difficulty. her neurological problem began during [**name (ni) **] time in [**2106-12-16**] when she experienced non-specific headache. a head ct showed no abnormality and her headache was thought to be from shingles. her headache resolved over time. in mid-[**2107-4-17**], she developed subacute onset of ""mixing her words"" as noted by her family members. she saw dr. [**first name4 (namepattern1) **] [**last name (namepattern1) **] on [**2107-5-12**] and a head mri performed elsewhere on [**2107-5-13**] showed a mass in the left inferior parietal brain. on [**2107-5-18**], she experienced lightheadedness and lost the ability to stand. her family called 911 and the ambulance brought her to the emergency department at [**hospital1 69**]. she was hospitalized and a gadolinium-enhanced head mri from [**2107-5-20**] showed a cystic enhancing mass in the inferior left parietal brain. ct of the torso was negative for masses. during her hospitalization she became agitated and anxious. oxazepam helped but sons are reporting that it wears off in mid-day. she was discharged home on [**2107-5-20**] for follow up in btc [**2107-5-23**] and she was referred to dr [**last name (stitle) **] on [**5-24**]. she has been without evidence of breast cancer disease since lumpectomy and radiation therapy in [**2092**]. past medical history: 1. recently-diagnosed brain lesions, as above (clinical deficit = mild language abnormalities, word-finding, paraphasic errors) 2. breast cancer s/p 0.4 cm grade i invasive ductal carcinoma. er+, pr+, her-2/neu -ve in [**2100**]. s/p chemo(tamoxifen), xrt, 2x lumpectomy. thought to be in remission. 3. cad s/p cabg [**2090**] 4. hypertension on bb and [**last name (un) **] 5. high cholesterol, now off statin due to adverse reaction 6. gerd w/ hiatal hernia, frequent symptoms 7. esophagitis 8. s/p ccy 9. s/p appy 10. s/p hysterectomy 11. djd / chronic low back pain 12. thyroid nodule 13. macular degeneration 14. pancreatic cysts 15. history of multiple prior utis, most recently in [**2106-4-16**] (e coli, treated with cipro). social history: she lives alone in [**location (un) 2312**]. husband died of cancer in [**2103**]. smoked 10 yrs but quit [**2055**], no etoh, no illicit drugs. family history: her parents are deceased; her mother had diabetes and [**name (ni) 2481**] disease while her father had stroke or myocardial infarction. three of her sisters died of breast cancer while one is alive with coronary artery disease and kidney cancer with pulmonary metastasis. physical exam: physical examination: temperature is 97.8 f. her blood pressure is 140/72. heart rate is 68. respiratory rate is 20. she has no pain. her skin has full turgor. heent examination is unremarkable. neck is supple and there is no bruit or lymphadenopathy. cardiac examination reveals regular rate and rhythms. her lungs are clear. her abdomen is soft with good bowel sounds. her extremities do not show clubbing, cyanosis, or edema. neurological examination: she is awake, alert, and able to follow some but not all commands. she has a receptive aphasia with intact fluency but poor repetition and comprehension. she can name a watch but not a tie. there is no right-left confusion. cranial nerve examination: her pupils are equal and reactive to light, 3 mm to 2 mm bilaterally. extraocular movements are full; there is no nystagmus or saccadic intrusion. visual fields are full to confrontation. her face is symmetric. facial sensation is intact bilaterally. her hearing is intact bilaterally. her tongue is midline. palate goes up in the midline. sternocleidomastoids and upper trapezius are strong. motor examination: she does not have a drift. she can move all 4 extremities well and symmetrically. her muscle tone is normal. her reflexes are 0-1 and symmetric bilaterally. her ankle jerks are absent. her toes are down going. sensory examination is intact to touch and proprioception. coordination examination does not reveal appendicular dysmetria or truncal ataxia. her gait is waddling but not from muscle weakness. she cannot do tandem gait. discharge exam: pt is alert oriented x2, incisionis c/d/i with monocrylsutures superficially. face symmetric, perrl, mild global aphasia, motor [**5-21**], sensory intact pertinent results: [**2107-5-26**] mr head w/ contrast *************** [**2107-5-25**] chest (pre-op pa & lat) pa and lateral chest radiographs: the cardiomediastinal and hilar contours are stable, with top normal heart size. the lungs are well expanded and clear, without consolidation, pleural effusion or pneumothorax. there is no pulmonary edema. multiple mediastinal surgical clips and intact sternotomy wires relate to prior cabg. impression: no acute cardiopulmonary pathology. [**2107-5-25**] mr functional brain by no significant changes are demonstrated in the left temporal and parietal lesions with associated vasogenic edema. limited study as only language paradigm could be obtained. one of the language activation areas is in close proximity to the lesion along its anterosuperior extent. the other language activation areas are not adjacent to the lesion. there is mild medial displacement of the arcuate fascicle by the lesion. [**2107-5-25**] cta head w&w/o c & reco 1. centrally-necrotic enhancing masses in the left posterior temporal and parietal lobes, unchanged from the recent mr of [**2107-5-20**], supplied by distal branches of the left mca and drained by tributaries to the left vein of [**last name (un) 70890**]. 2. mild perilesional edema and local mass effect upon the occipital [**doctor last name 534**] of the left lateral ventricle, but no associated hemorrhage, unchanged from the recent mr. 3. significantly decreased caliber of the basilar artery with 2.5 mm non-enhancing proximal-mid-basilar segment, new from [**2097-3-8**], likely representing interval development of severe steno-occlusive disease. [**2107-5-25**] cardiovascular echo the left atrium is normal in size. 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 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. trivial mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: normal global and regional biventricular systolic function. no clinically-significant valvular disease seen. [**5-27**] echo the left atrium is normal in size. 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 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. trivial mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: normal global and regional biventricular systolic function. no clinically-significant valvular disease seen. [**5-27**] ct head - 1. stable centrally necrotic masses in the left posterior temporal and parietal lobes, unchanged from [**2107-5-26**], without evidence of hemorrhage. no post-operative changes are seen. 2. mild perilesional edema with local mass effect on the occipital [**doctor last name 534**] of the left lateral ventricle, but no shift of normally midline structures. admission labs: [**2107-5-24**] 12:40pm blood wbc-6.9 rbc-4.22 hgb-12.7 hct-38.7 mcv-92 mch-30.1 mchc-32.7 rdw-13.0 plt ct-185 [**2107-5-24**] 12:40pm blood pt-12.4 ptt-27.8 inr(pt)-1.1 [**2107-5-24**] 12:40pm blood glucose-177* urean-15 creat-0.8 na-138 k-3.5 cl-100 hco3-28 angap-14 [**2107-5-24**] 12:40pm blood calcium-9.6 phos-2.8 mg-1.9 discharge labs: [**2107-5-30**] 06:50am blood wbc-10.7 rbc-4.16* hgb-12.7 hct-38.3 mcv-92 mch-30.5 mchc-33.1 rdw-13.0 plt ct-179 [**2107-5-30**] 06:50am blood glucose-133* urean-32* creat-0.8 na-136 k-4.2 cl-100 hco3-26 angap-14 [**2107-5-30**] 06:50am blood calcium-9.0 phos-2.7 mg-2.3 brief hospital course: patient was admitted to [**hospital1 18**] on [**5-24**] with a left parietal brain lesion. on [**5-25**] she underwent a cta of the head as well as a functional mri of the brain. she was seen by medicine for operative clearance who felt she needed no additional workup. on [**5-26**] she underwent mri wand study and there was a family dicussion with dr [**last name (stitle) **] regarding the surgery. she arrived in pre-op and was complaining of chest pain. a cardiac consult was called and the surgery was aborted. she was transferred to cardiology for futher management. serial enzymes were obtained which showed no evidence of elevation. she was optimized for surgery. on [**5-27**] a repeat echo showed no evidence of hypokiness with ef > 55%. she was then taken to or on [**5-27**]. post op ct showed expected post op changes. she c/o of left shoulder pain and enzymes were again negative. she did well postoperatively and remained stable during her floor course. pt/ot were consulted and they recommended home with 24-hour supervision. she also will be set up with vna for medication management. she was deemed fit for discharge on the afternoon of [**5-31**]. she was given instructions for followup and prescriptions for all required medications. pending results: left brain mass pathology final report [**2107-5-27**] transitional care issues: patient will need to follow up in brain [**hospital 341**] clinic for further recommendations regarding possible treatment of her l brain mass. this appointment has already been arranged for her. medications on admission: medications - prescription 6 mastectomy bras for breast cancer - - icd# 174.8 alprazolam - 0.5 mg tablet extended release 24 hr - 1 tablet(s) by mouth daily atenolol - 50 mg tablet - 1 tablet(s) by mouth twice a day manufactor teva per patient request dexamethasone - 1 mg tablet - [**1-17**] tablet(s) by mouth twice daily irbesartan [avapro] - 75 mg tablet - 1 tablet(s) by mouth twice a day lansoprazole [prevacid] - (dose adjustment - no new rx) - 30 mg capsule, delayed release(e.c.) - one capsule(s) by mouth twice a day - no substitution mylicon - - use 2 drops after each meal nitroglycerin [nitrostat] - 0.3 mg tablet, sublingual - 1 tablet(s) sublingually q5 minutes as needed for chest pain oxazepam - (dose adjustment - no new rx) - 10 mg capsule - 1 capsule(s) by mouth twice a day as needed partial breast prosthesis - - wear as needed daily icd9: 174.9 potassium chloride [klor-con m20] - (dose adjustment - no new rx) - 20 meq tablet, er particles/crystals - 0.5 (one half) tablet(s) by mouth daily triamterene-hydrochlorothiazid - 37.5 mg-25 mg tablet - [**1-17**] tablet(s) by mouth daily medications - otc aspirin - 81 mg tablet - one tablet(s) by mouth daily cholecalciferol (vitamin d3) - (prescribed by other provider) - 400 unit capsule - 1 capsule(s) by mouth twice a day cyanocobalamin (vitamin b-12) [vitamin b-12] - (prescribed by other provider) - dosage uncertain dextran 70-hypromellose [tears naturale] - drops - one eye four times a day ergocalciferol (vitamin d2) - (prescribed by other provider) - 400 unit capsule - one capsule(s) by mouth three times a day --------------- --------------- --------------- --------------- discharge medications: 1. simethicone 80 mg tablet, chewable [**month/day (2) **]: one (1) tablet, chewable po qid (4 times a day) as needed for indigestion. disp:*120 tablet, chewable(s)* refills:*0* 2. nitroglycerin 0.3 mg tablet, sublingual [**month/day (2) **]: one (1) tablet, sublingual sublingual prn (as needed) as needed for chest pain. 3. triamterene-hydrochlorothiazid 37.5-25 mg capsule [**month/day (2) **]: 0.5 cap po daily (daily). 4. cholecalciferol (vitamin d3) 400 unit tablet [**month/day (2) **]: one (1) tablet po twice a day. 5. acetaminophen 325 mg tablet [**month/day (2) **]: two (2) tablet po q6h (every 6 hours) as needed for pain or fever > 101.5: do not exceed 4,000mg of tylenol in a 24 hour period. disp:*240 tablet(s)* refills:*0* 6. irbesartan 150 mg tablet [**month/day (2) **]: 0.5 tablet po bid (2 times a day). 7. potassium chloride 10 meq tablet extended release [**month/day (2) **]: one (1) tablet extended release po daily (daily). 8. atenolol 50 mg tablet [**month/day (2) **]: one (1) tablet po once a day. 9. lansoprazole 30 mg tablet,rapid dissolve, dr [**last name (stitle) **]: one (1) tablet,rapid dissolve, dr po bid (2 times a day). 10. hydromorphone 2 mg tablet [**last name (stitle) **]: one (1) tablet po q6h (every 6 hours) as needed for pain. disp:*90 tablet(s)* refills:*0* 11. levetiracetam 500 mg tablet [**last name (stitle) **]: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*0* 12. quetiapine 25 mg tablet [**last name (stitle) **]: one (1) tablet po tid (3 times a day) as needed for agitation. disp:*90 tablet(s)* refills:*1* 13. oxazepam 10 mg capsule [**last name (stitle) **]: one (1) capsule po q6h (every 6 hours) as needed for anxiety. disp:*60 capsule(s)* refills:*0* 14. dexamethasone 2 mg tablet [**last name (stitle) **]: taper tablet po per instruction: 4mg po tid x 1 days, 3mg po tid x 2 days, 2mg po tid x 2 days, 2mg po bid and continue on current dose. disp:*120 tablet(s)* refills:*0* 15. outpatient physical therapy eval and treat 16. dextran 70-hypromellose drops [**last name (stitle) **]: one (1) drop ophthalmic every six (6) hours. 17. ergocalciferol (vitamin d2) 400 unit tablet [**last name (stitle) **]: one (1) tablet po three times a day. 18. cyanocobalamin (vitamin b-12) oral 19. aspirin 81 mg tablet, delayed release (e.c.) [**last name (stitle) **]: one (1) tablet, delayed release (e.c.) po once a day. 20. hospital bed please provide that patient with one [**hospital 105700**] hospital bed for home use. patient has a brain tumor icd-9 784.20 length of need: 1 year [**16**]. docusate sodium 100 mg capsule [**year (2 digits) **]: one (1) capsule po twice a day as needed for constipation. disp:*60 capsule(s)* refills:*0* discharge disposition: home with service facility: [**hospital 119**] homecare discharge diagnosis: left parietal tumor angina anxiety aphasia leukocytosis htn gerd discharge condition: mental status: clear and coherent, mild global aphasia 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. ?????? your wound closure uses 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 (do not take extra aspirin, you may take your daily baby aspirin), advil, and ibuprofen etc. ?????? 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. we made the following changes to your medications: 1) we stopped your alprazolam. 2) we stopped your mylican. 3) we increased your ozazepam to 4 times per day as needed for anxiety. 4) we increased your dexamethasone. on [**5-31**] you will take 4mg three times a day. on [**4-13**] you will take 3mg three times a day. on [**4-15**] you will take 2mg three times a day. on [**6-5**] and onwards you will take 2mg two times a day. 5) we started you on simethicone 80mg four times a day as needed for indigestion or gas. 6) we started you on tylenol 650mg every 6 hours as needed for pain or fever. do not exceed 4,000mg of tylenol in a 24 hour period as this can cause fatal liver damage. 7) we started you on hydromorphone 2mg every 6 hours as needed for pain. do not drive, operate heavy machinery, drink alcohol or take any sedating medications until you know how this medication effects you as it can cause dangerous sleepiness. 8) we started you on keppra 1,000mg twice a day. 9) we started you on seroquel 25mg twice a day as needed for anxiety. please continue to take your other medications as previously prescribed. it was a pleasure taking care of you on this hospitalization. followup instructions: follow-up appointment instructions ??????you have an appointment in the brain [**hospital 341**] clinic on [**6-6**] at 1pm. 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**]. please call if you need to change your appointment, or require additional directions. completed by:[**2107-5-31**]",1
124,"admission date: [**2166-8-20**] discharge date: [**2166-9-12**] date of birth: [**2113-10-15**] sex: f service: medicine allergies: lisinopril / toprol xl / lipitor / levofloxacin / compazine / vancomycin attending:[**first name3 (lf) 5755**] chief complaint: change in mental status major surgical or invasive procedure: endotracheal intubation and extubation central venous catheter placement history of present illness: 55 yo f with h/o cad s/p cabg, htn, dm2, pvd, cri with h/o episodes of arf, h/o hyperkalemia biba due to lethary. patient was feeling generally unwell since discharge from [**hospital1 18**] for episode of arf with cr was 2.3 (from baseline 1.1) and k 6.8 and le pain [**12-26**] pvd. per her son who has been staying with her since her discharge she was ambulatory. he reports that 2-3 days ago she started to become more lethargic, noted to be sleeping a lot, falling asleep during conversation then waking up and mumbling inconherently. her visiting nurse suggested she seek medical attention two days prior but patient refused to come back to the hospital. last night patient noted to be worsening per her son, c/o persistent pain, more lethargic, unable to walk, having to carry her to the bathroom and to the bedroom. this am when nurse came they convinced her to come to ed via ems. per her son she has been eating a little, drinking water, urinating normally. he has not noted any fevers, chills, cough, nausea/vomiting or diarrhea. . in the ed, vs: 95.0 60 120/70 16 100% nrb. given 0.4 narcan with no response. k hemolyzed but elevated to 7.8 given insulin/dextrose, calicum and kayexalate with improvement to 5.6. renal consult placed, no need for urgent dialysis. given 1 gram ceftriaxone for uti. cpap noninvasive ventilation attempted. abgs 7.24-7.26/55-64/100-200. given solumedrol 125 mg x 1, albuterol/atrovent nebs. . upon arrival to the icu, patient off cpap, sating 90-92% 4->2l nc. very difficult to arrouse, requires frequent prompting, states she felt unwell since discharge from hospital, denies cp, sob, denies pain. past medical history: 1. pvd: prior work-up at the [**hospital1 112**] 2. cad s/p cabg in [**2160**] at [**hospital1 112**] 3. dm 2 4. h/o cva - c/b residual numbness/weakness of left arm and leg 5. htn 6. hyperlipidemia 7. elevated lfts, unknown etiology (?nash) social history: she works for the department of mental retardation. she lives alone. her son lives in the same building. she smokes [**11-25**] ppd (used to be more) for ~15 years. she denies a history of alcohol/drug use. family history: (+)htn, dm; no fh cancer physical exam: vs: 97.0 bp 108/89 hr 70 rr 20 90% 2l gen: obese, somnolent, opens eyes with repeated prompting, speak in one-two word sentences, falls asleep, snoring, mumbling occasionally neck: obese, supple, unable to asses jvd heent: marked periorbital edema, perrl, anicteric, mmm chest: diffuse rhonchi, no wheezing/rales cvs: nl s1 s2, distant heart sounds, no m/r/g appreciated abd: obese, distended but soft, no hsm appreciated, no rebound/guarding, bs + ext: warm, dry atrophic skin with several crusted ulcerations (all appear old), [**12-27**]+ pitting edema to below the knee neuro: a+ox3 with prompting, moves all four extremities, not compliant with exam due to somnolence, responds to painful stimuli/prompting, appropriate to questions, mumbles intermittently pertinent results: [**2166-8-20**] 06:30pm glucose-88 urea n-50* creat-4.7* sodium-135 potassium-5.6* chloride-99 total co2-26 anion gap-16 [**2166-8-20**] 06:30pm alt(sgpt)-81* ast(sgot)-98* alk phos-158* amylase-58 tot bili-0.6 [**2166-8-20**] 06:30pm albumin-3.3* calcium-9.4 [**2166-8-20**] 06:30pm tsh-1.2 [**2166-8-20**] 05:02pm glucose-154* lactate-1.4 na+-130* k+-6.1* cl--99* [**2166-8-20**] 04:45pm wbc-7.9 rbc-2.92* hgb-8.8* hct-27.5* mcv-94 mch-30.2 mchc-32.0 rdw-15.7* [**2166-8-20**] 04:45pm asa-neg ethanol-neg acetmnphn-8.9 bnzodzpn-neg barbitrt-neg tricyclic-neg . micro: rpr non-reactive blood cultures [**2166-8-22**]: negative . [**2166-8-19**] ct head: there is no acute intracranial hemorrhage. there is no mass effect or shift of normally midline structures. the ventricles, sulci, and cisterns are unremarkable. the [**doctor last name 352**]-white matter differentiation is preserved. visualized paranasal sinuses are clear. the orbits are unremarkable. no acute fractures are identified. . tte [**2166-8-22**]: the left atrium is moderately dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is mildly depressed (ejection fraction 40-50 percent) secondary to hypokinesis of the basal segments of the inferior and posterior walls. tissue velocity imaging e/e' is elevated (>15) suggesting increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size and free wall motion are normal. the number of aortic valve leaflets cannot be determined. the aortic valve leaflets are moderately thickened. there is moderate aortic valve stenosis. mild to moderate ([**11-25**]+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. [due to acoustic shadowing, the severity of mitral regurgitation may be significantly underestimated.] moderate to severe [3+] tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. compared with the findings of the prior report (images unavailable for review) of [**2159-9-25**], moderate aortic stenosis is now present. . [**2166-8-21**]: rij hd catheter placement: uncomplicated ultrasound and fluoroscopically guided triple lumen temporary dialysis catheter placement via the right internal jugular vein approach with the tip positioned in the right atrium. . [**2166-8-25**]: ruq ultrasound: the study is significantly limited secondary to patient body habitus. limited views of the liver show no focal lesions. the common bile duct is presumed to be patent and measures approximately 2 mm. the polyp seen within the gallbladder on the previous exam is not seen on today's study. evaluation of the main portal vein with doppler shows hepatopetal flow, appropriately, but there are periods of intermittent neutral flow which could reflect portal hypertension. there is some fluid present in morison's pouch. brief hospital course: in brief, the patient is a 52 year old woman with history of cad s/p cabg, diabetes, hypertension, morbid obesity, chronic kidney disease (type 4 rta), and pvd who presented with subacute change in mental status. . # decreased mental status: the patient presented with decreased consciousness following a low impact fall at home. an initial head ct was negative for mass effect or bleeds. the etiology of her change in mental status was likely multifactorial secondary to obesity hypoventilation leading to hypercapnea and hypoxia, severe sleep deprivation from osa, worsening renal failure, +/- small contribution from hyperammonenia. other diagnostic possibilities that were negative included screen for drug intoxication, sepsis, thyroid dysfunction, or seizure. the patient was evaluated by the neurology service who thought the change was likely a toxic-metabolic picture. the endocrinology service was consulted and ruled out thyroid disfunction. the patient was found to have a mildly elevated ammonia level, but the remainder of her synthetic liver function was normal. she received lactulose titrated to [**11-25**] bowel movements per day. regarding her renal impairment, a renal consult was obtained and initiated hemodialysis after adequate access was acheived. the patient will need to have a sleep study as an outpatient to confirm the diagnosis of sleep apnea and to titrate cpap. in patient attempts at cpap were unsuccessful due to claustraphobia once the patient was more awake. upon transfer to the medical floor, the patient was awake and answering questions appropriately. she has had a normal mental status on the floor off all sedating meds. . # resp: the patients initial hypercapnea was thought secondary to copd and hypoventilation. she received nebulized bronchodilators according to her outpatient regimen. the patient did suffer a pea arrest likely triggered by worsening hypoxia of unclear etiology. cpr was initiated according to acls guidelines. she regained her blood pressure quickly following one round of epinephrine and atropine. she was intubated and mechanically ventilated, blood gases were monitored. she was weaned and extubated without complication. by time of transfer from the icu she was maintaing a normal o2sat on room air. attempts at cpap initiation were unsuccessful as described above. she has remained stable on room air while on the floor. . # acute on chronic rf. the patient's underlying chronic kidney disease is likely [**12-26**] htn/dm, type 4 rta on last admission, with concomitant uti (found on presentation). the acute worsening of her renal function was somewhat unclear as the time course was quite rapid of a decline, however, no triggering toxic exposure was identified. she completed a course of antibiotics for her uti. her urine output continued to decrease and a temporary hd catheter was placed. she was evaluated by the renal service who managed the dialysis sessions. she is currently on a qtues, thurs, sat schedule and is set up as an outpatient at [**last name (un) 106879**] [**location (un) **] to continue hemodialysis once she has completed her rehab stay. she is on a nephrocap and her electrolytes have been stable. . # hd catheter line infection: patient noted to have purulent discharge from her hemodialysis catheter site during hemodialysis. swab was sent and cultures were drawn off the line and peripherally but all culture data is negative to date. she received iv gentamicin which was discontinued given negative gram stain. she was continued on 7 days daptomycin for empiric treatment. suspect early diagnosis to explain negative cultures versus sterile seroma but opted to treat to protect new line placed on the left. the catheter on the right was discontinued. continue bacitracin cream to the incision site, which will need removal of stitches in the next couple of days. . # hypotn/hypoxia on hd: patient had an episode of transient hypotension and hypoxia while on hemodialysis on the day of the diagnosis of a suspected line infection. her blood pressure improved with a 200 cc bolus and her hypoxia resolved spontaneously. suspect transient bacteremia versus vancomycin allergic reaction (onset after 25 of 200 cc of vancomycin) versus overdialyzed. no recurrent episodes. . # cad s/p cabg. there were no acute issues during her icu stay as the patient denied cp and the ekg was non specific. unclear anatomy, ?grafts. currently not on optimal cad treatment due to past adverse reactions to beta-blockers and statins. the tnt was slightly elevated at 0.02, which was likely [**12-26**] renal dysfunction. tte with new as and chf on exam (pitting edema, unable to assess jvd d/t body habitus). she received aspirin. volume management was controlled by ultrafiltration. she was started on a low dose acei on the floor given low ef and esrd on hemodialysis (discussed with renal prior to initiation). . # dm. very poorly controlled as outpatient, last hba1c was 9.8% on [**6-29**]. on high dose glargine at home. during the hospital stay the patient had both hypo- and hyper-glycemia. [**initials (namepattern4) **] [**last name (namepattern4) **] consult was obtained. on the floor, her glargine has been increased based on her daily regular insulin requirement. . # anemia: patient has a baseline anemia with labs suggestive of iron deficiency. she is s/p 2 doses of iv iron and will need 3 more doses to correct her iron deficit. she will follow-up with her pcp to schedule an outpatient colonoscopy. folate/b12 were normal. spep and upep this admission negative. her admission was complicated with bleeding associated with a hemodialysis line placement. she required 2 u prbc for resuscitation. . # ppx. sc heparin, ppi, bowel reg . # fen: dm, cardiac diet . # dispo: # code: full (confirmed) . # access: piv, subclav hd cath . # communication: son [**name (ni) **] [**name (ni) **] [**telephone/fax (1) 106880**]; [**telephone/fax (1) 106881**], son trying to get poa (temporary) to be able to pay her bills. medications on admission: lasix 20 mg po daily - dipyridamole-aspirin 200-25 mg po bid - hydrocodone-acetaminophen 10-325 one tablet po q4h:prn - docusate sodium 100 mg capsule po bid - senna 8.6 mg tabletbid - gabapentin 100 mg po qhs - glyburide 10 mg po bid - cefpodoxime 100 mg tablet sig: two (2) tablet po q12h x 7 days [**8-15**] - ipratropium bromide 2 puff inhalation qid - albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation - fludrocortisone 0.1 mg po daily - glargine 37 u sq qhs discharge medications: 1. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 2. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 3. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 4. colace 100 mg capsule sig: one (1) capsule po twice a day. 5. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) capsule inhalation once a day. 6. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. salmeterol 50 mcg/dose disk with device sig: one (1) puff inhalation twice a day. 8. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed for pain: max = 2 grams per day. 9. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day). 10. neomycin-bacitracin-polymyxin ointment sig: one (1) appl topical qid (4 times a day): to right neck prn. 11. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 12. daptomycin 500 mg recon soln sig: four [**age over 90 1230**]y (450) mg intravenous once for 1 days: please give one dose [**2166-9-12**] after hemodialysis (then course complete). 13. ferric gluconate 125 mg qd x 3 days (may be given with hemodialysis) 14. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 15. glargine 38 units sq qhs 16. humalog insulin per sliding scale discharge disposition: extended care facility: [**hospital3 105**] northeast - [**location (un) 38**] discharge diagnosis: primary: obesity hypoventilation acute on chronic renal failure urinary tract infection hyperkalemia type 2 diabetes with poor control transaminitis s/p mechanical fall hemodialysis line infection secondary: history of coronary artery disease history of peripheral vascular disease history of poorly controlled type 2 diabetes, with complications discharge condition: good: alert, lytes stable, tolerating hemodialysis discharge instructions: please monitor for temperature > 101, change in mental status, low or high blood sugars, bleeding at hemodialysis catheter site, or other concerning symptoms. you may have an allergy to vancomycin, please avoid this medication in the future. followup instructions: [**last name (un) **] clinc [**9-30**] at 10:30 am, with dr. [**first name4 (namepattern1) **] [**last name (namepattern1) **]. phone: [**telephone/fax (1) 2384**] dr. [**last name (stitle) **] on wed [**2166-9-17**] at 1:00pm, [**hospital unit name **], [**hospital ward name 12837**], [**location (un) **] [**hospital unit name **]. phone: [**telephone/fax (1) 2395**] dr. [**first name4 (namepattern1) **] [**last name (namepattern1) 106882**] on [**9-22**], 4pm. [**hospital ward name 23**] 1. phone: [**telephone/fax (1) 250**]",1
125,"admission date: [**2167-5-12**] discharge date: [**2167-5-18**] date of birth: [**2092-2-13**] sex: m service: [**location (un) 259**] chief complaint: weakness. history of present illness: the patient is a 75 year old man whose past medical history includes renal cell cancer, status post partial right nephrectomy, prostate cancer, coronary artery disease, type 2 diabetes mellitus requiring insulin, hypertension, methicillin resistant staphylococcus aureus sputum, and clostridium difficile colitis, status post ileostomy. the patient was discharged from [**hospital1 346**] on [**2167-4-18**], for dehydration (? gastritis ?) and subsequently was transferred to rehabilitation. he was discharged from [**hospital **] rehabilitation on [**2167-5-8**]. he started an ace inhibitor at about this time. the patient was in his usual state of health until [**2167-5-12**], approximately four hours prior to his admission, when the patient attempted to get out of bed and fell due to weakness. the patient did not suffer any injuries or loss of consciousness from his fall. the patient was subsequently taken to the [**hospital1 69**] emergency department, where the patient's electrocardiogram revealed tall, peaked t waves and a widened qrs complex. his potassium was subsequently checked and found to be 10.1. the patient was then given two grams of calcium gluconate, intravenous insulin, amp of d50 and normal saline with two ampules of bicarbonate. a dialysis line was then placed in the right femoral artery, and the patient was subsequently transferred to the medical intensive care unit. at the time of admission, the patient noted that he had recently been started on an ace inhibitor approximately at the time of his discharge from [**hospital6 3953**]. in addition, the patient noted that he had chronically elevated potassium in the past, and that he has required bicarbonate, that he has been on sodium bicarbonate and kayexalate. at the time of his presentation, the patient admitted some left groin/left hip pain, which he thought to be musculoskeletal in origin. the patient denied other complaints including fever, chills, nausea, vomiting, diarrhea and constipation. the patient denies chest pain, shortness of breath, palpitations. the patient denies light-headedness or other focal neurological symptoms. the patient denies urinary symptoms, including dysuria, pyuria, hematuria. the patient denies melena or bright red blood per rectum. past medical history: 1. renal cell carcinoma, status post partial nephrectomy ([**12-22**]). 2. perioperative inferolateral myocardial infarction ([**12-22**]). 3. fulminate clostridium difficile colitis ([**1-23**]), requiring total colectomy. 4. history of pneumonia with methicillin resistant staphylococcus aureus positive sputum ([**12-22**]). 5. type 2 diabetes mellitus, requiring insulin. 6. hypertension. 7. diabetic nephropathy. 8. prostate cancer, status post radiation therapy. 9. hypercholesterolemia. 10. history of submandibular abscess in [**2161**]. medications on admission: 1. aspirin 81 mg p.o. once daily. 2. neurontin 300 mg p.o. four times a day. 3. lantus 56 units subcutaneous q.h.s. 4. prevacid 30 mg p.o. q.a.m. 5. lisinopril 5 mg p.o. twice a day. 6. reglan 10 mg p.o. twice a day with meals. 7. metoprolol 12.5 mg p.o. twice a day. 8. paxil 20 mg p.o. q.h.s. 9. zocor 20 mg p.o. q.h.s. 10. ambien 10 mg p.o. q.h.s. 11. imodium 2 mg p.o. four times a day p.r.n. allergies: adverse reactions - this patient states that he is allergic to penicillin and cephalosporins. in addition, the patient appears to develop hyperkalemia on ace inhibitors and arbs. social history: since the time of his discharge from [**hospital6 310**] on [**2167-5-8**], the patient has been living at home with a caretaker. the patient's sister lives in [**name (ni) **], [**state 350**] and is the [**hospital 228**] health care proxy. the patient's primary care physician is [**last name (namepattern4) **]. [**first name4 (namepattern1) **] [**last name (namepattern1) 1728**]. the patient denies any history of tobacco, alcohol or illicit or intravenous drug use. family history: noncontributory. review of systems: as above. the patient denies headache, head trauma, dizziness. the patient complains of discharge and pruritus of the eyes bilaterally, and he notes that he has recently been started on topical erythromycin for presumed conjunctivitis. the patient denies other visual changes. the patient denies any recent history of cough or sputum production. the patient denies shortness of breath, dyspnea on exertion, orthopnea, hemoptysis, wheezing. the patient denies paroxysmal nocturnal dyspnea, edema or any history of heart murmurs. the patient denies any history of hot or cold intolerance or preexisting muscle or joint pain. the patient denies any recent lymphadenopathy or any changes in sensation or strength. the patient denies recent travel or changes in diet. physical examination: upon admission, temperature is 97.2, heart rate 40s, blood pressure 133/50, respiratory rate 18, oxygen saturation 98% in room air. in general, the patient is a well developed, well nourished male appearing pale and looking his stated age, in no acute distress. head, eyes, ears, nose and throat - normocephalic and atraumatic. the sclerae were clear and anicteric, no proptosis. conjunctiva were injected, erythematous and there was discharge bilaterally from the eyes. the oropharynx was clear without erythema, injection, sores, lesions, exudate. moist mucous membranes. neck - trachea midline. the neck was supple without lymphadenopathy, thyromegaly or thyroid nodules. carotid pulses with normal upstrokes without audible bruit bilaterally. thorax and lungs - thorax symmetrical, no increased ap diameter or use of accessory muscles. bibasilar crackles. lungs otherwise clear to auscultation and resonant to percussion bilaterally with normal diaphragmatic excursions and i:e ratio. cardiac - jugular venous pressure less than five centimeters. bradycardic. normal s1 and physiologically split s2, no s3, s4, ejection or midsystolic clicks. no murmurs, rubs or gallops appreciated. abdomen - positive bowel sounds, colostomy in right lower quadrant, bag intact with moderate volume brown stool. abdomen otherwise soft, nontender, nondistended. no hepatosplenomegaly appreciated. no palpable abdominal aortic aneurysm or audible bruits. genitourinary - no costovertebral angle tenderness. extremities - no cyanosis, clubbing or edema. 1+ pedal pulses bilaterally. musculoskeletal - tenderness with hip compression bilaterally. skin - no rashes, pigmentation changes. neurologically, awake, alert and oriented times three. cranial nerves ii through xii are grossly intact. motor normal bulk, symmetry and tone. sensation intact to light touch throughout. no focal deficits. laboratory data: upon admission, complete blood count revealed white blood cell count 11.6, hemoglobin 15.3, hematocrit 46.1, platelet count 288,000. differential revealed 65% neutrophils, 24% lymphocytes, 4% monocytes, 6% eosinophils, 1% basophils. basic coagulation studies showed prothrombin time 12.4, partial thromboplastin time 19.1, inr 1.0. chemistries revealed sodium 134, potassium greater than 10, chloride 113, bicarbonate 15, blood urea nitrogen 44, creatinine 1.7, glucose 242. repeat potassium 10.1. total protein 7.8, albumin 3.9, globulin 3.9, calcium 9.8, phosphate 3.1, magnesium 2.5. cardiac - cpk 45, ck mb not performed because ck less than 100, troponin c less than 0.3. arterial blood gases - po2 60, pco2 37, ph 7.29, total co2 19, base excess negative 7. free calcium 1.37. urinalysis revealed specific gravity 1.009, trace blood, negative nitrites, protein, glucose, ketone, bilirubin, urobilinogen, leukocytes. microscopic urine examination - 0-2 red blood cells, 0-2 white blood cells, occasional bacteria, no yeast, 0-2 epithelial cells. urine chemistry - creatinine 29, sodium 72, potassium 50, chloride 105, total protein 9, protein to creatinine ratio 0.3. microbiology: urine culture no growth. imaging on admission: left hip radiograph - no fracture or dislocation detected involving the left hip. mild degenerative spurring is present. ap pelvis - no fracture or dislocation is detected about the pelvis. there are multiple radiation seeds overlying the prostate as well as surgical sutures and a right lower quadrant ostomy. electrocardiogram - sinus bradycardia at a rate of 44 beats per minute, first degree av block, right bundle branch block, left anterior fascicular block, wide qrs complex and peaked t waves, consistent with hyperkalemia. hospital course: 1. fen - hyperkalemia - in the emergency department, the patient was administered calcium gluconate, insulin, an ampule of d50, intravenous normal saline with two ampules of sodium bicarbonate. a renal consultation was then called, and a double lumen quinton catheter was then placed in the patient's right groin in anticipation of hemodialysis to dialyze off the patient's elevated potassium. the patient was then admitted to the medical intensive care unit and subsequently underwent hemodialysis on [**2167-5-12**]. following dialysis, the patient's potassium trended back toward his baseline of approximately 5.0. throughout the remainder of the patient's admission, his potassium remained between 4.4 and 5.4. with the patient's potassium stable, the patient's quinton catheter was removed on [**2167-5-13**]. the etiology of the patient's hyperkalemia was felt to be multifactorial, including a combination of baseline elevated potassium, noncompliance with outpatient kayexalate, diet at home, and medication induced with recent prescription of ace inhibitors at the outside hospital. other traditional causes of hyperkalemia include advanced renal failure, marked volume depletion and hypoaldosteronism. the patient's clinical and laboratory examination provided little evidence for either advanced renal failure or marked volume depletion, raising the question of hypoaldosteronism in its etiology. with these thoughts in mind, the patient subsequently had an aldosterone level drawn, and he was started empirically on fludrocortisone, for presumed hyporeninemic hypoaldosteronism, a condition that typically affects patients 50 to 70 years of age with diabetic nephropathy or chronic interstitial nephritis with mild to moderate renal insufficiency. in addition, it was noted that the patient may have been on heparin while at the outside hospital, and that heparin has been known to have a direct toxic effect on the adrenal zonaglomerulosa cells. the patient's course in the medical intensive care unit with respect to his hyperkalemia upon admission was otherwise uncomplicated, and he was subsequently transferred from the medical intensive care unit to the floor on [**2167-5-14**]. at the time of his transfer from the medical intensive care unit on [**2167-5-14**], the patient's renal medications included furosemide 20 mg p.o. once daily, fludrocortisone acetate 0.1 mg p.o. once daily, and sodium bicarbonate 1300 mg p.o. twice a day. in order to reduce the patient's potassium to a desire range of between 4.0 and 4.5, the patient's dose of fludrocortisone was increased from 0.1 mg p.o. once daily to 0.1 mg p.o. twice a day. at the time of his discharge on [**2167-5-18**], the patient had a potassium of 4.4. on the morning of the patient's discharge, the patient's previous aldosterone level came back from the laboratory. the patient's aldosterone was found to be 13.0 with a reference range of 1.0-16.0 for a patient when supine. at discharge, the patient was continued on his fludrocortisone at a dose of 0.1 mg p.o. twice a day with instructions to follow-up with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] in the [**hospital 2793**] clinic at [**hospital1 69**]. hypercalcemia - at the time of his admission, the patient's free calcium was noted to be 1.37. the elevated calcium occurring in the context of hyperkalemia raised the question of multiple myeloma, and the patient subsequently had an spep and upep sent. these tests revealed no specific abnormalities, and there was no monoclonal immunoglobulin seen. the patient's calcium at the time of discharge was 9.4. 2. endocrine - the patient has a history of type 2 diabetes mellitus requiring insulin. during the time of his admission, the patient was maintained on a regimen of glargine 54 units q.h.s. with a humalog sliding scale. hypoaldosteronism - as mentioned previously, the patient's presentation with hyperkalemia raised the question of hypoaldosteronism in its etiology. given the patient's history of type iv rta, it was thought that the patient's hypoaldosteronism might be due to hyporeninemic hypoaldosteronism, a condition that typically affects patients in their 50s to 70s with diabetic nephropathy or chronic interstitial nephritis with mild to moderate renal insufficiency. as mentioned above, at the time of his discharge, the patient's aldosterone returned at a level of 13.0, which was within normal limits of 1.0-16.0. while the patient was continued on his fludrocortisone at admission, he was scheduled to follow-up with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] of nephrology in the [**hospital 2793**] clinic as an outpatient. 3. renal - after the patient's one episode of hemodialysis on [**2167-5-12**], the patient's right quinton catheter was subsequently pulled and he required no further episodes of hemodialysis. during the remainder of his admission, the patient's creatinine remained between 1.0 and 1.5. as mentioned above, given the patient's presumed type iv rta and hyporeninemic hypoaldosteronism, the patient was continued on his fludrocortisone, initially at 0.1 mg p.o. once daily and subsequently on 0.1 mg p.o. twice a day. in addition, as has been noted in prior discharge summaries, it was again emphasized that the patient should avoid treatment with ace inhibitors and arbs. 4. cardiovascular - coronary artery disease - from the time of his emergency department presentation on [**2167-5-12**], the patient was ruled out for a myocardial infarction with three sets of cardiac enzymes, all of which were negative. the patient was continued on his aspirin, lopressor and statin. 5. infectious disease - conjunctivitis - the patient was continued on his erythromycin strips for bilateral conjunctivitis. 6. musculoskeletal - hip/groin pain - the patient's radiographs at the time of presentation in the emergency department provided no evidence of either hip or pelvic fracture or dislocation. while the patient continued to complain of some right groin pain, this pain was treated to good effect with heat packs and acetaminophen. weakness - while the patient's weakness precipitating his fall on [**2167-5-12**], might have been attributed to his hyperkalemia, the patient was also ruled out for hypothyroidism. the patient's tsh was 1.2 and his free t4 was 1.5, both within normal limits. in addition, the patient was seen by physical therapy, who felt that much of his weakness was due to deconditioning. following several sessions with the patient, physical therapy felt that the patient was safe to be discharged home with 24 hour supervision. condition on discharge: stable. discharge status: discharged to home with services. discharge diagnoses: 1. hyperkalemia. 2. type 2 diabetes mellitus requiring insulin. 3. coronary artery disease, status post myocardial infarction. 4. hypertension. 5. peripheral nephropathy. 6. renal call cancer. 7. prostate cancer. 8. history of clostridium difficile colitis. medications on discharge: 1. glargine insulin 54 units q.h.s. 2. humalog insulin sliding scale. 3. gabapentin 300 mg p.o. four times a day. 4. furosemide 20 mg p.o. once daily. 5. erythromycin ophthalmic ointment one strip o.u. six times per day. 6. fludrocortisone 0.1 mg p.o. twice a day. 7. lopressor 12.5 mg p.o. twice a day. 8. sodium bicarbonate 1300 mg p.o. twice a day. 9. aspirin 81 mg p.o. once daily. 10. loperamide 2 mg p.o. four times a day p.r.n. 11. reglan 10 mg p.o. q6hours. 12. zocor 20 mg p.o. once daily. 13. paxil 10 mg p.o. once daily. discharge instructions: the patient is to follow-up with his primary care physician, [**last name (namepattern4) **]. [**first name4 (namepattern1) **] [**last name (namepattern1) 1728**]. in addition, the patient is to schedule an outpatient appointment with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) **] at the [**hospital1 69**] [**hospital 10701**] clinic. [**first name11 (name pattern1) 312**] [**last name (namepattern4) **], m.d. [**md number(1) 314**] dictated by:[**name8 (md) 30463**] medquist36 d: [**2167-5-20**] 16:53 t: [**2167-5-20**] 18:50 job#: [**job number 107943**]",1
126,"admission date: [**2161-9-18**] discharge date: [**2161-9-22**] date of birth: [**2085-4-1**] sex: m service: medicine ccu history of present illness: this is a 75-year-old male with past medical history of coronary artery disease status post three vessel cabg in [**2156**]. he had a lima to the lad, saphenous vein graft to the pda, and saphenous vein graft to om-1. this was stented four years ago, congestive heart failure with an ejection fraction of 25%, chronic renal insufficiency, and left bundle branch block, who presented to the emergency room after an episode of bradycardia with his heart rate in the 30s, and was found to have 2:1 heart block. the patient states that he had been well until today. he exercised on a treadmill 30 minutes every 3-4 days. the morning of admission he noted some blurry vision, some nausea, vomiting and dizziness. he rested and the symptoms resolved. later in the morning he had three further episodes of lightheadedness with standing, but no syncope. he had taken his blood pressure and it was 116/60 with a heart rate of 35. he called his pcp, [**last name (namepattern4) **]. [**last name (stitle) **], who had told him to go to the emergency room. the patient denied any chest pain, shortness of breath, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, increasing edema, or palpitations. he has had a history of syncopal episode in [**2161-12-12**], after which he was admitted to [**hospital **] hospital. all of his cardiac workup had been negative. he did have a stress test at that time, and a 24 hour holter monitor, which did not show an explanation for his syncope. the patient has not recently had any medication changes or any new medications added to his regimen. review of systems: he has no other complaints. no numbness or tingling, no loss of bowel or bladder continence. no fever or chills. no abdominal pain. no recent insect bites. in the emergency room, he had a right ij placed through which a temporary wire was placed, and he was vvi paced at 50 with a threshold of 0.5 to 1 milliamps. past medical history: 1. coronary artery disease status post myocardial infarction and coronary artery bypass graft in [**2156**]. 2. congestive heart failure with an ejection fraction of 20-25%. 3. gout. 4. hypertension, normal runs 116/60. 5. prostate cancer status post xrt and hormone therapy. 6. obese. 7. ocular melanoma in his left eye status post proton-beam therapy. 8. chronic renal insufficiency. 9. cholecystectomy. medications: 1. aspirin 325 q day. 2. zestril 20 q day. 3. metoprolol 50 [**hospital1 **]. 4. lipitor 20 q day. 5. terazosin 2 mg q hs. 6. folic acid. 7. flonase nasal spray. 8. [**doctor first name **] 60 q day. 9. allopurinol 100 q day. 10. zantac. allergies: he has an allergy to contrast dye years ago when he had his cholecystectomy. since then, he has received contrast and had no adverse reactions. social history: he is married with two children. he has social alcohol use in his teen years. no recent alcohol use, no tobacco smoking. family history: his father died at 68 of ""cardiac causes."" physical examination: vital signs in the emergency room, he was afebrile. his temperature was 97.5, blood pressure 125/47, heart rate of 50, which was ventricular paced, sating 96% on room air. in general, he was an elderly white male sleeping comfortably in bed in no apparent distress. heent: pupils are equal, round, and reactive to light and accommodation. extraocular movements are intact. sclerae are anicteric. cardiovascular: regular, rate, and rhythm, normal s1, s2. no murmurs, rubs, or gallops. no jugular venous distention, no carotid bruits. respiratory: lungs are clear to auscultation bilaterally. abdomen is soft, nontender, nondistended, bowel sounds are present, no masses, guarding, or rebound tenderness, no hepatosplenomegaly. extremities: no cyanosis, clubbing, or edema. he did have an area of 3 x 2 erythematous lesion on his left shin, which looked like a tinea infection. laboratories on admission: his white count was 6.6, hematocrit was 29.4, which was down from his baseline of 34. his chem-7 was within normal limits. his cpk was 99, troponin was negative. studies: electrocardiogram on admission at 4:16 showed 2:1 heart block with an atrial rate of 70, ventricular rate of 35 consistent with second degree a-v delay type two. he also has an underlying left bundle branch block with a p-r interval of 320. electrocardiogram at 18:17 just showed paced rhythm, heart rate of 50. the patient was admitted to medicine to the ccu service. hospital course by systems: 1. cardiovascularly: for coronary arteries, he was continued on his aspirin, lipitor, and ace inhibitor. his beta blocker was held given the risk of complete heart block and his heart rate being in the low 50's. his cardiac enzymes were cycled and they were all negative. of note, the date after admission, his electrocardiogram was consistent with complete heart block. otherwise throughout his hospital stay, he was v-paced. the patient was awaiting permanent pacemaker placement on [**last name (lf) 766**], [**first name3 (lf) **] the temporary pacemaker wire was left in until he had his permanent pacemaker. myocardium: the patient's ejection fraction was 20-25%. this was unchanged. he was continued on his current medical management as he had no signs or symptoms of congestive heart failure at this time. the patient was started on the 11th on cefazolin 1 gram q8 x6 doses prior to pacemaker placement. on the afternoon of the 11th, the pacemaker was placed without event. the patient was started on vancomycin 1 gram q12h x4 doses. chest x-ray post pacemaker placement showed the leads in good position. 2. heme: the patient's hematocrit had decreased from his baseline. a repeat hematocrit showed the hematocrit to be 28.5. stool guaiac was done and it was negative, yet it was felt to be anemia secondary to blood loss, and the patient was transfused 1 unit. after the 1 unit, the patient's hematocrit remained stable throughout his hospital course. 3. renal: the patient has chronic renal insufficiency. his hematocrit was at his baseline. his ace inhibitor was continued as he was medically stable on this regimen. 4. pulmonary wise: the patient took fluticasone and atrovent as an outpatient, so he was continued on is outpatient inhalers. 5. rheum: the patient has a history of gout. he was continued on his allopurinol. 6. allergy: he has seasonal rhinitis. he was continued on his [**doctor first name **]. 7. prostate cancer status post xrt and hormone therapy: he was continued on his terazosin. 8. infectious disease/tinea: the patient was started on lamisil cream [**hospital1 **]. 9. fluids, electrolytes, and nutrition: the patient did have some magnesium replaced on the 11th, and the patient was in stable condition throughout his hospital course. he was discharged home the day after pacemaker placement. he remained afebrile throughout his hospital course and had no events overnight on telemetry. discharge instructions: if he experienced any symptoms prior to those he experienced before his pacemaker was placed, had been given an instructions book about pacemakers, and if he were to have any questions he was given the number from the pacemaker clinic. he is to take all of his regular medicines per his normal routine except for the metoprolol. he was discharged with percocet for pain. he is to take one tablet every 4-6 hours prn as needed. he was to continue using the cream for his rash for seven days. if this did not clear in seven days, to contact his pcp or dermatologist. he was being discharged on a three day course of keflex. he was instructed to take one tablet po four times a day for three days and to take all pills. final diagnosis: 1. status post pacemaker placement. 2. complete heart block. 3. coronary artery disease status post coronary artery bypass graft. 4. congestive heart failure. 5. gout. 6. tinea infection. 7. prostate cancer. 8. chronic renal insufficiency. recommended followup: follow up at your [**hospital **] clinic within the next week and call for the appointment. major surgical or invasive procedures: he had an ep study and a ddd pacemaker placement. discharge condition: stable. discharge medications: 1. [**doctor first name **] 60 mg capsule po q day. 2. atorvastatin 20 mg po q day. 3. terazosin one 2 mg tablet po q hs. 4. allopurinol 100 mg po q day. 5. aspirin 325 mg po q day. 6. terbinafine 1% cream applied topically [**hospital1 **] as needed for rash x5 days. 7. lisinopril 20 mg po q day. 8. percocet one tablet po q4-6 as needed for pain. 9. keflex 250 mg capsule po qid x3 days. condition on discharge: stable. [**first name8 (namepattern2) 2064**] [**last name (namepattern1) **], m.d. [**md number(2) 2139**] dictated by:[**name8 (md) 8736**] medquist36 d: [**2161-9-24**] 21:34 t: [**2161-9-27**] 11:17 job#: [**job number 106188**] cc:[**last name (namepattern1) **]",0
127,"admission date: [**2177-5-28**] discharge date: [**2177-5-30**] date of birth: [**2128-8-30**] sex: m service: [**company 191**] history of present illness: the patient is a 47 year-old male with a history of depression, hepatitis c and seizures who used heroin daily this past fall and presented to the emergency department by ambulance after being found lethargic by his partner at home. the night and morning prior to admission according to the patient he ingested an overdose of drugs that may have included ativan, wellbutrin, seroquel, depakote, neurontin and heroin. the predominant ingestions reportedly were ativan, wellbutrin, depakote and heroin. he did have some non-bloody, non-bilious emesis prior to admission and had no history of trauma. he denies this was a suicide attempt. he says he took the pills in an effort to ""escape"". he has consistently denied any suicidal ideation since his admission. he reports multiple, recent stressors including having his mother move, unemployed and a conflict with his partner. on admission he denied any chest pain, shortness of breath, abdominal pain, headaches or myalgias. past medical history: 1. hepatitis c. 2. seizures. 3. history of one psychiatric admission at [**hospital 1680**] hospital. 4. multiple overdoses with no history of detox or rehabilitation. 5. daily heroin use with the most recent relapse in [**2176-9-7**]. 6. depression. 7. possible history of bipolar disorder denied by patient and partner. admission medications: 1. wellbutrin 150 [**hospital1 **]. 2. depakote 1500 q hs. 3. neurontin 300 tid. 4. seroquel 50 tid. note: he denies that he has been taking any other these recently. allergies: possible adverse reaction to lithium. social history: daily heroin use. denies current alcohol or tobacco use. he does have a history of alcohol use in the past. history of ativan use in the fall. no other drug use. review of systems: notable for fatigue. also notable for bright red blood per rectum, [**9-7**]. physical examination: the patient is a lethargic appearing male in mild distress. vital signs: temperature 99 f, blood pressure 150/100, pulse 88, respiratory rate 20. heent - mucous membranes are moist. pupils are equal, round and reactive to light and accommodation. oropharynx - erythema. neck is supple. lungs are clear to auscultation bilaterally, resonance to percussion. heart - regular rate and rhythm, normal s1, s2, no murmurs, rubs, or gallops. abdomen - soft, nontender, nondistended. neuro - cranial nerves ii through xii are intact. the patient is alert and oriented times person and place but he notes that the date is [**2128**]. his speech is slow. he is moving all extremities. extremities - no cyanosis, clubbing or edema. laboratory data: white count 6.1, hematocrit 45.2, differential 53 polys, 40 lymphs, 4 monos, 2 eosinophils. urinalysis is negative. sodium 146, potassium 3.7, chloride 105, co2 24, bun 13, creatinine 0.8, glucose 75, alt 49, ast 27, ldh 204, alkaline phosphatase 118, total bilirubin 0.4, amylase 31, lipase 18. calcium 8.4, magnesium 2.7, phos 4.2. ammonia 87, valproic acid 243. serum tox screen negative. urine tox screen negative. ekg normal sinus rhythm with left axis deviation and early r wave progression. hospital course: 1. overdose - the patient ingested two sustained released medications wellbutrin and depakote therefore there is some worry that his cns depression will continue to deteriorate but it did not. the patient gradually improved on the first night of admission. his valproic level decreased over night from 250 to 150. he became gradually less lethargic and more oriented though he did require 6 mg of ativan over night for agitation. he was kept in the micu over night for monitoring but was transferred out on hospital day one. initially his ammonia level was elevated at 87 decreased to 61 on hospital day one. his lfts normalized rapidly. he was maintained on the ciwa scale with a one to one sitter without events. psychiatry was involved throughout and it was decided the patient should be discharged to an inpatient psychiatric facility. the patient was also written for haldol prn for agitation, 5 mg iv q 30 minutes prn. however he did not require any doses while he was in the hospital. 2. cardiovascular - the patient underwent three ekgs during his admission all of which were largely unremarkable with no qt prolongation as can happen with a seroquel overdose. telemetry monitoring during his admission revealed only mild tachycardic events that were brief and occurred only approximately two times. he was maintained on telemetry throughout his admission. 3. respiratory - the patient saturations were well throughout his admission and showed no signs of respiratory depression. 4. gastrointestinal - the patient did not have significant gi symptoms including no constipation and no abdominal pain, no evidence of hepatic toxicity which can be associated with depakote. the patient has had bright red blood per rectum since [**2176-9-7**] that is most consistent with hemorrhoids. he has been advised to follow up with this as an outpatient. 5. fluids, electrolytes and nutrition - the patient was taking good po by hospital day one. his electrolytes were closely monitored as his multiple ingestions could certainly cause electrolyte abnormalities. depakote particularly can cause anion gap metabolic acidosis. the patient did have a potassium on hospital day one of 3.3 which was repleted. all of his electrolytes normalized by the end of his admission. in summary this 47 year-old male presented one day post poly drug overdose with cns depression. he was followed by psychiatric throughout his admission and is near his baseline functioning and is ready for an inpatient psychiatric admission. discharge diagnosis: 1. poly drug overdose. discharge medications: 1. ativan 1 mg iv q one hour prn for withdraw for ciwa scale greater than 10. 2. haldol 5 mg iv q 30 minutes prn for agitation. discharge condition: stable. discharge status: to inpatient psychiatric facility. [**last name (lf) **],[**first name8 (namepattern2) **] [**first name8 (namepattern2) **] [**last name (namepattern1) **] m.d.12-735 dictated by:[**last name (namepattern1) 101665**] medquist36 d: [**2177-5-30**] 10:41 t: [**2177-5-30**] 11:59 job#: [**job number **] 1 1 1 dr",1
128,"admission date: [**2157-11-12**] discharge date: [**2157-11-18**] service: medicine allergies: penicillins / procainamide / decongestant / novocain / beta-adrenergic agents / sulfonamides / captopril / enalapril / hydralazine / erythromycin base / nifedipine / paroxetine / sertraline attending:[**first name3 (lf) 5827**] chief complaint: hypoxia major surgical or invasive procedure: picc line placement history of present illness: 85 y.o. female with multiple medical problems, most pertinently, aspiration pna and restrictive lung disease (on amiodarone for atrial fibrillation)who presents from her nursing home with desaturation into the 80s. patient was reported to be in her normal state of health until today when she was noted to be awake and oriented x 3, but withdrawn and lethargic. patient was noted to be hypoxic to the 80s on room air and was brought into the ed for further evaluation. patient was also complaining of back and hip pain, which are both chronic, but denied chest pain. in the ed, vitals were significant for: t - 99.3, hr - 70, bp - 118/55, rr - 14, o2 - 100 nrb. a cxr showed a possible pna and a head ct was ordered for question of mental status changes, but patient was awake, alert and oriented x 3 and refused the head ct. she was given vancomycin, levofloxacin and flagyl for the presumed pna and admitted to the icu because of high oxygen requirement - nrb. patient is dnr/dni. . of note, patient was hospitalized here at [**hospital1 18**] from [**date range (1) 47017**] for back pain and change in mental status, the latter of which was felt to be due infection as the patient had a ua suggestive of a uti (no culture was done). she was also noted to be transiently hypoxic at this time, but cxr was unremarkable. she was treated with levofloxacin for her uti and on discharge, no longer had an oxygen requirement. past medical history: 1. tachy/brady s/p ddi pacemaker ([**12-25**]) -[**company 1543**]. 2. htn 3. af with cva/tia in [**2153**], on coumadin and amiodarone. echo [**10/2154**]: mild [**name prefix (prefixes) **] [**last name (prefixes) 1915**], mild lvh, ef>55%. mild to mod mr, mild to mod pulmonary htn pasp 38. 4. quinidine-induced lupus c/b pericardial effusion s/p stripping 5. aspiration pneumonia 6. restrictive lung dz on pfts in [**6-/2156**] fvc and fev1 near 45% predicted. 7. psoriasis 8. spinal stenosis s/p l4-5 laminectomy and spinal fusion ?????? wheelchair bound since [**2141**] 9. ?left hip replacement s/p fall 10. depression 11. urinary incontinence social history: social history: lives in [**hospital3 2558**], a nursing home. husband died suddenly at age 50. has a son and a daughter, and 5 ??????[**name2 (ni) **]?????? grandkids. retired 11 years ago from working at [**hospital1 756**] as a collection officer. 30py history of smoking, quit 35 years ago. no alcohol use, no illegal drug use. family history: htn and mi in paternal side??????father died of mi. mother died of aneurysm. no diabetes. no cancer. physical exam: vitals: t - 96.7, bp - 162/57, hr - 73, rr - 23, o2 - 100% on 15 nrb (92% on ra) general: awake, alert, nad heent: nc/at; perrla, eomi; op clear neck: supple, no lad, no jvd chest/cv: s1, s2 nl, no m/r/g appreciated lungs: poor inspiratory effort, but decreased bs on the left abd: soft, nt, nd, + bs ext: no c/c/e neuro: grossly intact skin: multiple nevi noted, particularly on back pertinent results: ekg: sinus at 70, lad, prolonged pr, borderline widened qrs, no acute st changes . imaging: cxr ([**11-12**]): ap and lateral views of the chest are obtained in the upright position. patient rotation somewhat limits evaluation. there is increased pulmonary opacity at the left lung base which may represent evolving pneumonia, though technique is suboptimal, limits assessment. there is stable plate-like atelectasis at the right lung base. cardiomediastinal silhouette is stable. atherosclerotic calcification along the aortic knob is noted. a small left-sided pleural effusion is noted. visualized osseous structures are intact. a left-sided pacer device is seen with lead tips terminating in the approximate location of the right atrium and right ventricle. . 143 104 31 -------------< 118 4.9 30 1.2 . wbc: 16.4 hct 35 plt 382 n:83.9 l:11.1 m:3.4 e:1.3 bas:0.2 . pt: 41.4 ptt: 66.5 inr: 4.5 brief hospital course: ms. [**known lastname **] is an 85 y.o. female with desaturations at nursing home and lll infiltrate with leukocytosis, concerning for pna. hosp course by problem: . # aspiration pneumonia: diagnosed via imaging as above. we initiated with levofloxacin, metronidazole, and vancomycin given recent hospitalization and nh status. recurrent pna, altered ms, and poor swallow apparatus worrisome for aspiration. swallow c/s ordered that recommended ground solids and honey-thickened liquids. on discharge, she will continue vancomycin iv for 6 weeks for below. . # sepsis and presacral abscess.: l-spine showed presacral abscess abutting l5/s1 that probably contributed to of pt's back pain and leukocytosis. transient micu stay. surgical consult was obtained. source thought to be hematogenous seeding of presacral area. patient not a candidate for percutaneous ct guided drainage per interventional radiology. her preoperative functional status precluded surgical intervention, per surgical team. therefore, we elected medical management with 6 week course of antibiotics, vancomycin, levofloxacin, and metronidazole. she will need repeat ct scan in 6 weeks, which has been scheduled for [**2157-12-26**]. if there is persistence of abscess, then she will need to continue antibiotics longer. . # atrial fibrillation/tachy/brady: s/p pacemaker. on coumadin, initially supratherapeutic and was reversed with oral vitamin k. warfarin resumed. additionally, now on levofloxacin which will interact with coumadin. will need to monitor inr closely. also on amiodarone, atenolol and verapamil. . # back pain: likely secondary to presacral abscess. continue lidocaine patch and gabapentin. .. # depression: on phenelzine as an outpatient which was continued. . # delirium: pt delirious in micu which subsequently improved with pain control, antibiotics for infection and relief of constipation. we treated pain with minimally sedating meds and treated her infection. we used low-dose haldol prn. continued outpatient zyprexa . # rigidity and masked facies: seen on micu rounds. ? parkinson's disease. will need monitoring as outpatient. . # code status: dnr/dni . # contact: [**name (ni) **] [**name (ni) 12056**] [**telephone/fax (1) 102830**] medications on admission: lactulose 30 ml po daily acetaminophen 325-650 mg po q6h:prn levofloxacin 500 mg po q24h amiodarone 200 mg po daily multivitamins 1 cap po daily atenolol 50 mg po daily olanzapine 5 mg po daily bisacodyl 10 mg pr hs:prn pantoprazole 40 mg po q24h calcium carbonate 500 mg po bid phenelzine sulfate 15 mg po bid clonazepam 0.5 mg po qhs senna 1 tab po bid docusate sodium 100 mg po bid fluticasone propionate nasal 2 spry nu [**hospital1 **] verapamil sr 120 mg po q24h gabapentin 300 mg po hs vitamin d 400 unit po daily heparin 5000 unit sc tid warfarin 1 mg po daily . allergies/adverse reactions: penicillins / procainamide / decongestant / novocain / beta-adrenergic agents / sulfonamides / captopril / enalapril / hydralazine / erythromycin base / nifedipine / paroxetine / sertraline discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 2. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 3. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 4. hexavitamin tablet sig: one (1) cap po daily (daily). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. phenelzine 15 mg tablet sig: one (1) tablet po bid (2 times a day). 7. fluticasone 50 mcg/actuation spray, suspension sig: two (2) spray nasal [**hospital1 **] (2 times a day). 8. gabapentin 300 mg capsule sig: one (1) capsule po hs (at bedtime). 9. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 10. olanzapine 5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po daily (daily). 11. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: one (1) adhesive patch, medicated topical qd (). 12. atenolol 50 mg tablet sig: one (1) tablet po daily (daily). 13. verapamil 180 mg tablet sustained release sig: one (1) tablet sustained release po q24h (every 24 hours). 14. docusate sodium 50 mg/5 ml liquid sig: five (5) ml po bid (2 times a day). 15. warfarin 2 mg tablet sig: one (1) tablet po daily16 (once daily at 16). 16. vancomycin in dextrose 1 gram/200 ml piggyback sig: one (1) gram intravenous q 24h (every 24 hours) for 4 weeks: to complete final dose of antibiotics on [**2157-12-24**]. gram 17. metronidazole in nacl (iso-os) 500 mg/100 ml piggyback sig: five hundred (500) mg intravenous q8h (every 8 hours) for 4 weeks: to complete last dose of 6 week course on [**2157-12-24**]. 18. levofloxacin in d5w 750 mg/150 ml piggyback sig: seven [**age over 90 1230**]y (750) mg intravenous q48h (every 48 hours) for 4 weeks: to complete last dose of 6 week course on [**2157-12-24**]. discharge disposition: extended care facility: [**hospital3 2558**] - [**location (un) **] discharge diagnosis: primary: aspiration pneumonia, bacteremia, presacral abscess. secondary: restrictive lung disease, atrial fibrillation, htn, tachy/brady syndrome s/p pacemaker, depression, hearing loss discharge condition: hemodynamically stable and afebrile. discharge instructions: you were admitted for low oxygen saturation and delirium. you had aspiration pneumonia, bloodstream infection, and infection in your pelvis. you were started on antibiotics which need to be continued for a total of 6 weeks. please continue these antibiotics as prescribed. please continue all your medications as prescribed. you facility will be provided a copy of all your medications and will continue to administer them to you. . please keep all your outpatient appointments. . please return to the ed or seek medical care if you notice new fevers, chills, worsening back pain, painful urination, diarrhea, worsening mental status or for any other symptom for which you are concerned. followup instructions: you will be followed by your facility physician while at your extended-care facility. upon discharge, you should schedule an appointment with your primary doctor, dr. [**first name4 (namepattern1) **] [**last name (namepattern1) 6680**] at [**telephone/fax (1) 608**]. you have been scheduled for a follow-up ct scan on [**2157-12-26**] at 2:00 pm at the [**hospital ward name 23**] clinical center, [**location (un) 3387**], [**location (un) **]. please do not eat for 3 hours prior to the scan, and please have full bladder 1 hours before scan. please call [**telephone/fax (1) 327**] with any questions. completed by:[**2157-11-18**]",1
129,"admission date: [**2172-8-18**] discharge date: [**2172-9-1**] date of birth: [**2105-4-12**] sex: m service: vsurg allergies: penicillins / meperidine attending:[**first name3 (lf) 4748**] chief complaint: abdominal aortic aneurysm major surgical or invasive procedure: aaa resection with abf graft history of present illness: 67/y/o male with history of lteft leg claudication and known abdominal aortic aneurysm which has increased in size. now admitted for surgical repair past medical history: htn s/p l cea [**6-5**] aaa 5.3cm x 5.6cm thoracic descending aa dm-diet controlled depression anxiety laryngeal cancer s/p resection and xrt compression fracture osteomyelitis of right jaw s/p bone graft social history: lives with sister and nephew. +tobacco 50 pack-years. no ivdu. former etoh. sober 25 years. family history: mother--ich at 72yo pertinent results: [**2172-8-18**] 08:15pm wbc-6.7 rbc-2.96* hgb-9.5* hct-26.8* mcv-91 mch-32.1* mchc-35.5* rdw-15.3 [**2172-8-18**] 08:15pm plt count-177 [**2172-8-18**] 08:15pm pt-14.2* ptt-30.3 inr(pt)-1.3 [**2172-8-18**] 03:00pm type-art po2-462* pco2-51* ph-7.33* total co2-28 base xs-0 [**2172-8-18**] 02:48pm glucose-151* urea n-13 creat-0.6 sodium-139 potassium-3.4 chloride-106 total co2-25 anion gap-11 [**2172-8-18**] 02:48pm calcium-9.5 phosphate-4.9* magnesium-1.1* brief hospital course: patient admitted to preoperative holding area [**2172-8-13**] [**2172-8-18**] aaa repair with aortobifemoral bypass graft with intra operative epidural catheter placement.transfered to pacu extubated and stable.post operative hct. 26.8 transfused two units of prbc's. patient in pacu developed new onset of left arm and legnumbness .blood pressure controlled with improvement of left sided symptoms. epidural also held and solution changed and neurological symptoms rsolved. patient stablized and was transfered to vicu for continued care.patient continued to required high doses of iv nitro which was converted to niprid with improvement of blood pressure. [**2172-8-19**] pod#1 episode of confusion after recieving benadryl for ""itching"". also pulled out arterial line and epidural catheter. this required haldol of total dose of 8mgm to manage confusion and agitation.lopressor was began for hypertension. nasogastric tube clamping trial was began. 8/19-20/04 pod #[**2-4**] remained in vicu. requiring lasix for moblization of fluids. [**2172-8-22**] pod #4 tolerating nasogastric tube clamping. tpn insutued. swan catheter converted to triple lumen subclavian line.antihypertensive s continued to require dosing adjustment. patient remained in vicu. [**2172-8-23**] pod# 5 ambulation to chair began. physical thearphy evaluation recommended continued physical thearphy on daily basis should be able to be discharged to home. if gastric drainage residual less 200cc plan discontinue nasogastric tube.remained in vicu. [**2172-8-24**] pod#6 clear liquids began and tpn rate of infusion decreased. [**2172-8-25**] pod#7 tpn dicontinued. tolerating oral intake. perioperative clindamycin discontinued.transfered to nursing floor for continued care. [**2172-8-26**] pod#8 evaluated by physical thearphy. would require continued following prior to discharge on a daily basis by physical therphy. [**2172-8-27**] pod#9 noted right foot to be cooler than left on am exam during attending rounds. arterial pvr's demonstrated signficant flow defecit.reutrned to surgery. s/p right fmoral thromboembolectomy, endartectomy,right femoral -popiteal by pass graft with ptfe, right lower extremity introperative angiogram.he was transfered to pacu with palpable graft pulse and dp pulse. [**2172-8-28**] pod# [**10-2**] patient was seen by psyhciarty. patient refusing his antipsychotic medications.sequol discontinued since patient not taking on a regular basis but nardal continued.will followup with his phsyhiatric when discharged. psychiatry did not find any contraindiactions to dicharge to home when mediacally stable. [**2097-8-28**] pod# 11/12/2/3 continued to progress with stable [**month/day/year 1106**] exam. foley discontinued, centeral ine discontinued and abdominal stable were discontinued. [**2172-8-31**] pod# 13/4 discharged to home stable condition. medications on admission: same as d/c medications discharge medications: 1. acetaminophen 650 mg suppository sig: one (1) suppository rectal q4-6h (every 4 to 6 hours) as needed. 2. metoprolol tartrate 50 mg tablet sig: one (1) tablet po tid (3 times a day). 3. phenytoin sodium extended 100 mg capsule sig: one (1) capsule po tid (3 times a day). 4. atorvastatin calcium 10 mg tablet sig: one (1) tablet po qd (once a day). 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 6. lisinopril 20 mg tablet sig: one (1) tablet po qd (once a day). 7. quetiapine fumarate 25 mg tablet sig: five (5) tablet po qd (once a day). 8. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 9. donepezil hydrochloride 10 mg tablet sig: one (1) tablet po hs (at bedtime). 10. phenelzine sulfate 15 mg tablet sig: two (2) tablet po qam (once a day (in the morning)). 11. phenelzine sulfate 15 mg tablet sig: three (3) tablet po qpm (once a day (in the evening)). 12. hydralazine hcl 50 mg tablet sig: one (1) tablet po q6h (every 6 hours). 13. clonidine hcl 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). discharge disposition: extended care facility: [**doctor first name 391**] bay [**hospital **] nursing and rehab center discharge diagnosis: abdominal aortic aneurysm right femoral thromobembolism s/p right femoral thromboelectomy wit right fem-[**doctor last name **] bypass graft with ptfe adverse reaction to benadryl discharge condition: stable discharge instructions: continue all medicatiions as instructed may shower, no tub baths no driving until seen followup with dr. [**last name (stitle) 1391**]. [**name8 (md) 138**] md [**first name (titles) **] [**last name (titles) 26520**] redness,swelling or drainage from groin or leg wounds. [**name8 (md) 138**] md [**first name (titles) **] [**last name (titles) 26520**] fever followup instructions: 2 weeks with dr. [**last name (stitle) **]. call for appointment [**telephone/fax (1) 1393**] followup with dr. [**last name (stitle) 1007**] post discharge followup with dr.[**first name (stitle) **] post discharge completed by:[**2172-8-31**]",1
130,"admission date: [**2150-4-20**] discharge date: [**2150-4-27**] date of birth: [**2096-10-22**] sex: f service: neurology allergies: ativan attending:[**first name3 (lf) 5831**] chief complaint: confusion, headache major surgical or invasive procedure: none history of present illness: [**known firstname **] [**known lastname **] is a 53 year-old woman who was brought into the ed by her husband after she was confused and not making sense this morning at home. she has a notable history of paraplegia secondary to motor-vehicle accident in [**2142**] with t1/2 cord injury. she was recently hospitalized from [**4-14**] - [**4-16**] after she developed yellow productive sputum with a likely right lower lobe consolidation. she was treated w/ vancomycin, cefepime and azithromycin for a healthcare associated pneumonia (hcap) and discharged on [**4-16**]. she was also found to have a multidrug resistant klebsiella uti and was started on vanc/zosyn for a 14 day course. her husband and primary caregiver at home felt that the evening prior to admission she was at her baseline which they describe as communicative, pleasant and with mobility in her upper extremities. on [**4-20**] she awoke stating that she had a bad headache (further description unobtainable) and she was no longer making sense. she continued to repeat phrases and was not following commands. she was brought into the ed. during her time in the ed she was noted to have a seizure for around 1 minute which consisted of deviation of the head to the right with eyes to the right. she also had tonic contraction of both arms. this resolved spontaneously and was then given 2 mg of versed (hx of adverse reaction to ativan). her caregiver reports that she had one seizure in the past, around 1 year ago in the setting of multiple medication discontinuation (including - baclofen). she also has a history of pres in the setting of a micu admission in [**2147-12-3**] in which systolic blood pressures were greater than 160s. she had binocular vision loss during the episode and mri with occipital lobe flair hyperintensities. she is unable to provide any additional history. her husband states that at home her blood pressure typically run in the 90s-110s systolic. past medical history: # t1 to t2 paraplegia status post a motor vehicle accident. # recurrent pneumonia (followed by pulm - last [**2149-4-9**]) - per pulm, recurrent pneumonia likely from pulmonary toilet issues secondary to neuromuscular disease with improvement with consistent and aggressive bronchopulmonary therapy. - prior sputum cultures + for mrsa, pan-sensitive klebsiella, and pseudomonas. # recurrent utis in the setting of urinary retention requiring straight catheterization # copd # hepatitis c # anxiety # dvt in [**2142**] -ivc filter placed in [**2142**] # pulmonary nodules # hypothyroidism # chronic pain # chronic gastritis # anemia of chronic disease # s/p pea arrest during hospitalization in [**2147-10-3**] social history: lives at home with husband and 2 adolescent children. - tobacco: 35-pack-years, has tried to quit but smokes intermittently. - alcohol: denies. - illicits: denies. family history: mom - lung cancer dad - healthy physical exam: afebrile; 116-190s/70s-110s p 90s r 30s spo2 95% facemask general: awake, cooperative, nad. heent: nc/at neck: supple, no carotid bruits appreciated. no nuchal rigidity pulmonary: ctabl cardiac: rrr, no murmurs abdomen: soft, nontender, nondistended extremities: no edema, pulses palpated skin: no rashes or lesions noted. neurologic: -mental status: continuously repeating phrases ""yes, ok, yes, ok"". not following simple appendicular or midline commands. -cranial nerves: i: olfaction not tested. ii: perrl 5 to 2mm and sluggish. blinks to threat b/l. funduscopic exam revealed no papilledema, exudates, or hemorrhages. iii, iv, vi: eyes midline and will track to the left, not moving past midline to the right v: reacts to stimuli on both sides of face [**year (4 digits) **]: no facial droop, facial musculature symmetric. viii: reacts to auditory stimuli b/l ix, x: palate elevates symmetrically. [**doctor first name 81**]: unable to test xii: unable to test -motor: diminished bulk in le, flaccid tone in le. no adventitious movements, such as tremor, noted. has b/l movements of arms that are purposeful and symmetric, some resistance b/l at the triceps. no movement of legs (chronic) -sensory: reacting to stimuli on ue b/l -dtrs: [**name2 (ni) **] tri [**last name (un) 1035**] pat ach l 2 2 2 0 0 r 2 2 2 0 0 plantar response was muted bilaterally. -coordination: unable to test -gait: unable to test given paraplegia . exam on discharge: . unchanged except for the following mental status exam: alert, oriented x3, language normal, attention: able to recite months of year backwards, short-term memory: [**4-5**] words @ 5minutes, slight perseveration, pertinent results: labs on admission: [**2150-4-20**] 09:45am pt-12.5 ptt-29.9 inr(pt)-1.2* [**2150-4-20**] 09:45am plt count-218# [**2150-4-20**] 09:45am neuts-79.0* lymphs-14.4* monos-2.9 eos-3.1 basos-0.6 [**2150-4-20**] 09:45am wbc-9.1 rbc-3.84* hgb-10.0* hct-33.7*# mcv-88 mch-26.0* mchc-29.7* rdw-16.4* [**2150-4-20**] 09:45am asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg [**2150-4-20**] 09:45am albumin-3.8 calcium-9.2 phosphate-3.8# magnesium-2.3 [**2150-4-20**] 09:45am lipase-16 [**2150-4-20**] 09:45am alt(sgpt)-30 ast(sgot)-22 alk phos-78 tot bili-0.2 [**2150-4-20**] 09:45am glucose-119* urea n-9 creat-0.5 sodium-146* potassium-3.6 chloride-99 total co2-40* anion gap-11 [**2150-4-20**] 09:51am lactate-1.0 [**2150-4-20**] 10:17am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-8.0 leuk-neg [**2150-4-20**] 10:17am urine color-straw appear-clear sp [**last name (un) 155**]-1.007 [**2150-4-20**] 10:17am urine uhold-hold [**2150-4-20**] 10:17am urine hours-random [**2150-4-20**] 12:16pm cerebrospinal fluid (csf) wbc-3 rbc-1100* polys-45 lymphs-45 monos-10 [**2150-4-20**] 12:16pm cerebrospinal fluid (csf) wbc-9 rbc-3* polys-43 lymphs-45 monos-12 [**2150-4-20**] 12:16pm cerebrospinal fluid (csf) protein-79* glucose-71 [**2150-4-20**] 12:35pm urine bnzodzpn-neg barbitrt-neg opiates-neg cocaine-neg amphetmn-neg mthdone-neg [**2150-4-20**] 12:35pm urine hours-random imaging studies: . [**2150-4-20**] ct_head impression: significant motion artifact limits evaluation. white matter hypodensity in the left parietal lobe may represent sequela of prior event of pres. . note added at attending review: although the left frontal hypodensity might be a sequelum of prior pres, the mr examination of [**2147-12-29**] did not demonstrate abnormality in this location. further, there is loss of grey white contrast, but no atrophy, as might be expected if this were an old lesion. these findings raise concern of acute-subacute infarction, or perhaps swelling after a seizure. mr is recommended for further evaluation. this revised interpretation was noticed at 5:25 pm, and discussed by telephone, by dr. [**last name (stitle) **], with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 22924**] of the emergency department at 5:30pm. [**2150-4-19**] eeg impression: this is an abnormal portable eeg due to the presence of frequent left temporal and left hemisphere sharp and slow wave discharges occurring for a few seconds at a time at 1 hz indicative of an epileptogenic focus in this region. however, the study was severely limited by abundant and frequent movement artifact during the majority of the study, and the rightsided electrodes were most severely affected. the background was otherwise slow and disorganized reaching up to a maximum of [**6-7**] hz posteriorly indicative of a moderate to severe encephalopathy. given the above findings, we suggest 24 bedside eeg monitoring for further diagnosis. [**2150-4-24**] ct-head impression: hypodensities in bilateral occipital, left temporal, and left frontal lobes are not significantly changed since the prior exam, and may represent pres or post-seizure changes. mri is recommended for further evaluation. brief hospital course: ms. [**known lastname **] is 53 yo woman with t1-t2 level paraplegia since [**2142**], with previous history of episode of pres, was in [**hospital1 **] with pneumonia and uti last week, home for 4 days when she developed headache and confusion. she came in to er, was hypertensive to sbp of 170's-180's and dbp in 110-120 range, had a focal seizure and severe encephalopathy. on [**2150-4-20**] she was admitted to the icu and her hypertension was treated with nicardipine iv. she was loaded with [**date range 13401**] for possible seizures. she was given acyclovir empirically for possibility of hsv encephalitis and underwent a lumbar puncture. she was treated empirically for mdr uti and possible pna with vancomycin/cepefime/flagyl. she underwent nchct which showed hypodensities consistent with pres with possibility of acute-subacute infarct. given her overall improvement, she was transfered to the floor on [**2150-4-22**]. she remained afebrile and her bp was well controlled. her csf did not show hsv and acyclovir was discontinued. her other abx were also stopped. on [**2150-4-22**], she had an extended routine eeg which did not show electrographic seizures or clear spikes. her [**date range 13401**] was continued for seizure prophylaxis as she did not have any other episodes concerning for seizure. to evaluate the hypodensity seen on previous scan, she was ordered for mri brain but refused. she was then ordered for a repeat nchct which showed stable changes consistent with pres. she will be discharge home to resume her typical pre-admission home services. transitional issues: . 1. pres: this is the second episode since [**2147**]. given her paraplegia, she is at risk for dysautonomia and hypertensive crises which have required inpatient hospitalizations for bp control. her bp is somewhat labile and attempts to start low dose bp control meds (lisinopril) have led to significant hypotension. going forward, she might benefit from bp cuff with prn bp control at home. she should continue her typical home care to limit pain, constipation or other triggers of hypertension. . 2. pulmonary function: she has chronic recurrent pna and followed by pulmonary service. she has pfts tomorrow and ongoing home chest-pt which she will continue on discharge. . 3. sleep apnea: during this hospitalization, she had several episodes of desaturations (80s) at night despite being on 2lnc. it is [possible that her likely sleep apnea is contributing to htn. we will recommend a sleep study as outpatient. . 4. seizures: these were likely provoked by pres. for the moment, she will remain on [**name (ni) 13401**] prophylactically until neurology follow-up. medications on admission: albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization [**name (ni) **]: one (1) inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. baclofen 10 mg tablet [**name (ni) **]: two (2) tablet po bid (2 times a day). baclofen 10 mg tablet [**name (ni) **]: one (1) tablet po once daily at 4 pm. calcium carbonate 200 mg calcium (500 mg) tablet, chewable [**name (ni) **]: two (2) tablet, chewable po twice a day. citalopram 40 mg tablet [**name (ni) **]: one (1) tablet po once a day. 6. ipratropium bromide 0.02 % solution [**name (ni) **]: one (1) inhalation every six (6) hours as needed for shortness of breath or wheezing. 7. levothyroxine 112 mcg tablet [**name (ni) **]: one (1) tablet po daily (daily). 8. clonazepam 1 mg tablet [**name (ni) **]: one (1) tablet po three times a day as needed for anxiety. 9. lidocaine 5 %(700 mg/patch) adhesive patch, medicated [**name (ni) **]: three (3) adhesive patches, medicated topical daily (daily). 10. methadone 5 mg tablet [**name (ni) **]: one (1) tablet po tid (3 times a day). 11. omeprazole 20 mg capsule, delayed release(e.c.) [**name (ni) **]: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 12. oxybutynin chloride 5 mg tablet [**name (ni) **]: one (1) tablet po once daily at 4 pm. 13. oxybutynin chloride 5 mg tablet [**name (ni) **]: two (2) tablet po bid (2 times a day). 14. polyethylene glycol 3350 17 gram powder in packet [**name (ni) **]: one (1) powder in packet po daily (daily). 15. pregabalin 100 mg capsule [**name (ni) **]: one (1) capsule po tid (3 times a day). 16. simvastatin 10 mg tablet [**name (ni) **]: one (1) tablet po once a day. 17. sucralfate 1 gram tablet [**name (ni) **]: one (1) tablet po tid (3 times a day). 18. oxycodone 5 mg tablet [**name (ni) **]: one (1) tablet po q8h (every 8 hours) as needed for pain. 19. trazodone 100 mg tablet [**name (ni) **]: one (1) tablet po hs (at bedtime) as needed for insomnia. 20. azithromycin 250 mg tablet [**name (ni) **]: one (1) tablet po q24h (every 24 hours) for 3 days. disp:*3 tablet(s)* refills:*0* 21. prednisone 10 mg tablet [**name (ni) **]: two (2) tablet po once a day: friday, then 1 tablet daily saturday/sunday. disp:*4 tablet(s)* refills:*0* 22. vancomycin 500 mg recon soln [**name (ni) **]: 1250 (1250) mg intravenous q 12h (every 12 hours) for 23 doses. disp:*23 inj* refills:*0* 23. piperacillin-tazobactam-dextrs 4.5 gram/100 ml piggyback [**name (ni) **]: one (1) intravenous q8h (every 8 hours) for 32 doses. disp:*32 inj* refills:*0* discharge medications: 1. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization [**name (ni) **]: one (1) inhalation q6h (every 6 hours) as needed for dyspnea. 2. baclofen 10 mg tablet [**name (ni) **]: two (2) tablet po bid (2 times a day). 3. baclofen 10 mg tablet [**name (ni) **]: one (1) tablet po q 24h (every 24 hours). 4. calcium carbonate 200 mg calcium (500 mg) tablet, chewable [**name (ni) **]: two (2) tablet, chewable po twice a day. 5. citalopram 20 mg tablet [**name (ni) **]: two (2) tablet po daily (daily). 6. ipratropium bromide 0.02 % solution [**name (ni) **]: one (1) inhalation q6h (every 6 hours) as needed for dyspnea. 7. levothyroxine 112 mcg tablet [**name (ni) **]: one (1) tablet po daily (daily). 8. clonazepam 1 mg tablet [**name (ni) **]: one (1) tablet po tid (3 times a day). 9. lidocaine 5 %(700 mg/patch) adhesive patch, medicated [**name (ni) **]: one (1) adhesive patch, medicated topical daily (daily). 10. methadone 5 mg tablet [**name (ni) **]: one (1) tablet po tid (3 times a day). 11. omeprazole 20 mg capsule, delayed release(e.c.) [**name (ni) **]: one (1) capsule, delayed release(e.c.) po twice a day. 12. oxybutynin chloride 5 mg tablet [**name (ni) **]: two (2) tablet po bid (2 times a day). 13. oxybutynin chloride 5 mg tablet [**name (ni) **]: one (1) tablet po q24h (every 24 hours). 14. polyethylene glycol 3350 17 gram powder in packet [**name (ni) **]: one (1) powder in packet po daily (daily). 15. pregabalin 25 mg capsule [**name (ni) **]: four (4) capsule po tid (3 times a day). 16. simvastatin 10 mg tablet [**name (ni) **]: one (1) tablet po daily (daily). 17. sucralfate 1 gram tablet [**name (ni) **]: one (1) tablet po three times a day. 18. oxycodone 5 mg tablet [**name (ni) **]: one (1) tablet po q8h (every 8 hours) as needed for pain. 19. trazodone 50 mg tablet [**name (ni) **]: two (2) tablet po hs (at bedtime) as needed for anxiety. 20. acetaminophen 650 mg/20.3 ml solution [**name (ni) **]: one (1) po q6h (every 6 hours) as needed for headache. 21. levetiracetam 500 mg tablet [**name (ni) **]: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*3* discharge disposition: home with service facility: [**hospital1 **] vna discharge diagnosis: encephalopathy pres syndrome seizure 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 for confusion and headaches and were found to have very high blood pressure. you also may have had a seizure. you confusion was thought to be the result of either high blood pressure or the result of an infection. both your high blood pressure and possible infection were treated and you improved. the antibiotics were stopped. an anti-seizure medication was started. you were closely monitored over the next several days and your condition improved every day. you should follow up with the neurologist once you leave the hospital. you should follow up with the pulmonary doctor once you leave the hospital given the concern for sleep apnea. you may benefit from a sleep study to ensure that your oxygen level does not decrease at night. you should continue respiratory therapeutic maneuvers every day. during your hospitalization, you were noted to have several high blood pressure readings. you should discuss starting a medication to help treat this. please note the following medication changes start - [**hospital1 13401**] (to help prevent seizures, this medication might be stopped by your neurologist in the future) stop: - please continue taking all your other medication as prescribed by your physicians. followup instructions: department: pulmonary function lab when: thursday [**2150-4-30**] at 1:10 pm with: pulmonary function lab [**telephone/fax (1) 609**] building: [**hospital6 29**] [**location (un) **] campus: east best parking: [**hospital ward name 23**] garage department: pft when: thursday [**2150-4-30**] at 1:30 pm department: medical specialties when: thursday [**2150-4-30**] at 1:30 pm with: drs. [**name5 (ptitle) 4013**] & [**doctor last name **] [**telephone/fax (1) 612**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) **] campus: east best parking: [**hospital ward name 23**] garage department: neurology when: [**2150-5-13**] 02:30p with: [**doctor last name 43**],[**doctor last name **] where: sc [**hospital ward name **] clinical ctr, [**location (un) **] neurology unit cc8",1
131,"admission date: [**2178-2-8**] discharge date: [**2178-2-14**] date of birth: [**2120-6-4**] sex: m history of present illness: this is a 57-year-old gentleman with human immunodeficiency virus, end-stage renal disease (on hemodialysis), hepatitis b, hepatitis c, cirrhosis, history of iv drug use (currently on methadone), history of history of pancreatitis, who is status post a recent [**hospital1 1444**] admission from [**1-13**] through [**1-22**] for hypotension and found to have markedly decreased left ventricular ejection fraction compared to three years ago. this was attributed to human immunodeficiency virus cardiomyopathy. following the past admission, the patient was started on captopril. highly had been off of that therapy for approximately 10 months secondary to pancreatitis. admission in [**2177-2-22**] was for pancreatitis which was attributed to antiretroviral medications. the patient was discharged to [**hospital1 **] two weeks ago for cardiac rehabilitation. the patient has complained of chest pain and abdominal pain times two weeks. today, the patient returned from hemodialysis and complained of mild abdominal pain for which he took tylenol. several hours later the patient complained of lightheadedness, worsening chest pain especially with inspiration. the patient was found to be in rapid wide complex tachycardia at 150 beats per minute, systolic blood pressure of 60, treated with lidocaine 100 mg times one and then 4 mg lidocaine drip and converted to normal sinus rhythm at the [**hospital1 69**]. cardiology was consulted in the emergency department, the ventricular tachycardic strip was interpreted as probably atrial flutter with 2:1 conduction, at which time the lidocaine was discontinued. the patient described nausea, vomiting, fever, chills, and dark/loose stool earlier in the day. he was found to have elevated amylase and lipase, and his laboratories were also hemolyzed. in the emergency department the patient was given aspirin, kayexalate for a potassium of 5.8, started on levofloxacin 250 mg p.o., flagyl 500 mg p.o., vancomycin 1 g iv times one, and morphine 4 mg iv times two, and a clot was sent to the blood bank. the patient was in normal sinus rhythm and tachycardic at 100 to 110 with a temperature of 100.5, blood pressure of 116 to 130/78 to 83, oxygen saturation 93% to 96% on 4 liters. the patient was transferred from the emergency department to the medical intensive care unit for observation. he also had a right femoral catheter placed at the time of admission. past medical history: 1. human immunodeficiency virus diagnosed in [**2159**] with a cardiomyopathy revealing severe left ventricular global hypokinesis, right ventricular hypokinesis described on echocardiogram on [**2178-1-13**]. this was a new finding compared to previous studies. his human immunodeficiency virus was with a cd4 count of 139; most recent viral load of 31,429 off antiretroviral treatment secondary to pancreatitis in [**2177-2-22**]. those medications, however, were restarted on [**2177-1-14**], at the time of admission he was taking antiretroviral medication. 2. history of iv drug use, on methadone. 3. end-stage renal disease, on hemodialysis times two years. the renal disease was secondary to membranoproliferate glomerulonephropathy versus iga nephropathy. 4. the patient also has chronic lung disease and hypoventilation times four years on 4 liters oxygen by nasal cannula. 5. he has a history of pe and deep venous thrombosis, on coumadin, dose ranging from 2.5 mg to 5 mg. 6. history of hepatitis b and hepatitis c. 7. cirrhosis. 8. splenomegaly. 9. pancreatitis (two episodes of acute pancreatitis in the past). 10. anemia. 11. hemorrhoidal bleeds. 12. benign prostatic hypertrophy. 13. depression. 14. history of methicillin-resistant staphylococcus aureus and vancomycin-resistant enterococcus. 15. history of thrush. 16. ppd positive treated for four months with inh. 17. history of peptic ulcer disease. medications on admission: compazine 10 mg p.o. q.6h., coumadin 8 mg p.o. q.d. (as documented in the medical intensive care unit admission note), senokot 2 tablets p.o. q.h.s., lanoxin 0.125 mg p.o. q.o.d. on even days, tylenol 650 mg p.o. q.6h., epogen 6000 units subcutaneous twice a week at hemodialysis, tums [**2176**] mg p.o. t.i.d. with meals, anusol ointment p.r.n., methadone 50 mg p.o. q.d., captopril 12.5 mg p.o. t.i.d., diazepam 10 mg p.o. q.i.d. p.r.n., colace 100 mg p.o. b.i.d., multivitamin with minerals 1 tablet p.o. q.d., prevacid 30 mg p.o. q.d., percocet 2 tablets q.4-6h. p.r.n., zoloft 50 mg p.o. q.d., bactrim 1 tablet every monday, wednesday and friday, 3-tc 25 mg p.o. q.d., d4t 20 mg p.o. q.d., neoflex 1 tablet b.i.d., and lactulose 20 cc p.o. p.r.n. allergies: haldol gives him a rash. thorazine causes anaphylaxis. codeine causes unknown adverse reaction as does stelazine. h2 blockers cause thrombocytopenia. clindamycin gives him a rash. social history: he is married with two daughters and one son. [**name (ni) **] lives with his wife and son. former iv drug use (heroin). past history of ethanol abuse. smoked two packs per day times 20 years; quit 10 years ago. on methadone since [**2162**]. family history: his father passed away of unknown causes. mother passed away of myocardial infarction at age 75. brother was killed in [**country 3992**]. sister is alive and well. physical examination on admission: on admission to the medical intensive care unit with a temperature was 100.5, blood pressure 116/74, heart rate 100, respiratory rate 18, oxygen saturation 96% on 4 liters. in general, a thin chronically ill-appearing 57-year-old gentleman in no acute distress. heent revealed pupils were equal, round and reactive to light. extraocular movements were intact. sclerae were icteric. thrush seen on the tongue. neck was supple. no lymphadenopathy. no jugular venous distention. cardiovascular revealed tachycardic with a systolic ejection murmur heard at the right lower sternal border. chest had fine crackles, left greater than right, at the bases. no wheezes. abdomen was soft and nondistended, generalized tenderness especially in the epigastric area. no rebound, active bowel sounds. liver and spleen both palpable. extremities revealed no cyanosis, clubbing or edema. palpable dorsalis pedis pulses. neurologically, alert and oriented times three. cranial nerves were grossly intact. no asterixis. laboratory data on admission: white blood cell count 6.3, hematocrit 33.5, platelets 104 with 74% polys and 19% lymphocytes. pt 20.3, inr 2.7, ptt 35.8. fibrinogen 277, albumin 2.6. calcium 8.8, phosphate 4.3, magnesium 2. alt 142, ast 623, ldh 3700, alkaline phosphatase 147, total bilirubin 1.4, lipase 2170, amylase 896. first creatine kinase was 94. troponin was sent and was pending. sodium 138, potassium 5.8, chloride 101, bicarbonate 23, bun 44, creatinine 6.4, and glucose 89. digoxin level was also sent and was pending. arterial blood gas was 7.29, lactate 3.1, free calcium 1.14, dat was sent off. blood cultures sent times two. chest x-ray showed no congestive heart failure, no infiltrates. electrocardiogram showed sinus tachycardia, left atrial dilatation, right bundle-branch block with new q waves in iii and avf. no st changes. hospital course: this 57-year-old gentleman with human immunodeficiency virus, end-stage renal disease, hepatitis b, hepatitis c, cirrhosis, cardiomyopathy, presented with ventricular tachycardia following hemodialysis as well as hypotension and was initially admitted to the medical intensive care unit for observation and was subsequently transferred the next morning to the [**hospital ward name **]. his hospital course by issue is as follows. 1. cardiovascular: the patient had no further episodes of his wide complex tachycardia which was thought to be more likely atrial flutter with aberrancy; however, ventricular tachycardia could not be ruled out. he also had a positive troponin to 13.5 with flat creatine kinases. there were electrocardiogram changes, but the overall opinion from cardiology was that the troponin leak as well as electrocardiogram changes could all be consistent with a cardiomyopathy. the digoxin was discontinued. the captopril was held. telemetry was continued, and the patient continued to show ventricular bigeminy and trigeminy with some premature ventricular contractions on telemetry, but did not have any further tachy arrhythmias. 2. gastrointestinal: the patient was had pancreatitis by elevated amylase and lipase in the setting of restarting his human immunodeficiency virus medications. he was kept n.p.o. with low maintenance iv fluids. his human immunodeficiency virus medications were held. a cat scan of the abdomen was done which showed a small stone in the gallbladder with no evidence of biliary obstruction, atrophic kidneys, small bilateral pleural effusions as well as fat stranding surrounding the tail of the pancreas, and a small amount of fluid collecting around the liver and anterior left renal fascia. findings were determined to be consistent with early pancreatitis, and the patient was treated as previously mentioned. also, an mrcp was obtained and gastrointestinal was consulted. the mrcp showed choledocholithiasis without any obstruction, most likely the cause of his intermittent pancreatitis. he declined ercp and was started on ursodiol. 3. renal: the patient was continued on hemodialysis every other day. he had minimal fluid intake with maintenance fluids, and his electrolytes were followed closely. he required only one dose of kayexalate to normalize his potassium, and otherwise did not require any other adjustments in his electrolytes. 4. hematology: the patient had multiple blood draws that were hemolyzed. he was coombs antibiotic positive with decreased haptoglobin and increased ldh. the source of his hemolysis was thought to be due to medications; possibly the captopril or the bactrim or the human immunodeficiency virus medications. his hemolysis laboratories progressively continued to improve with the ldh and the haptoglobin normalizing. his reticulocyte count was 3.3, and his hematocrit dropped to 25 but increased to 30 after 1 units of packed red blood cells. a hematology consultation was obtained, and they proposed doing a bone marrow biopsy to rule out a lymphoproliferative disorder or a lymphoma in this human immunodeficiency virus positive patient; however, the patient declined that procedure. the patient's inr increased to 8. he was given one dose of vitamin k at which time it came down to 1.8. he was restarted on 2.5 mg of coumadin and increased to 5 mg of coumadin. the patient received 8 mg of coumadin in the medical intensive care unit, after which time his inr increased significant; however, after the patient received vitamin k and was restarted on the coumadin the inr was followed to try to achieve a level of between 2 and 3 for adequate anticoagulation. 5. pulmonary: the patient has obstructive sleep apnea and a chronic oxygen requirement, chronic deep venous thrombosis and pe. he was continued on supplemental oxygen throughout the hospitalization, and his oxygen saturation was stable. 6. pe/deep venous thrombosis: again, the coumadin was restarted at 2.5 mg and then 5 mg with a goal inr of 2 to 3. 7. infectious disease: haart medications were held, as was the bactrim, in the setting of hemolysis. the patient had [**2-25**] blood culture bottles positive for staphylococcus coag-negative. two bottles were oxacillin resistant, and two were oxacillin sensitive. the patient received seven days of vancomycin dosed by level due to his renal failure. surveillance cultures were sent times two. at the time of this dictation, those cultures showed no growth to date. the plan was to restart his bactrim once he is taking better p.o. following resolution of the pancreatitis and once the hemolysis has resolved. the patient was also known to have methicillin-resistant staphylococcus aureus as well as vancomycin-resistant enterococcus and precautions were in place during his hospitalization. 8. psychiatry: the patient has a history of depression and iv drug use. he was continued on methadone. the zoloft and the diazepam were held while his was n.p.o., and he was maintained on valium p.r.n. discharge disposition: the patient was ultimately transferred to the [**hospital **] rehabilitation facility in good condition with the following discharge diagnoses. discharge diagnoses: 1. human immunodeficiency virus. 2. cardiomyopathy. 3. end-stage renal disease. 4. pancreatitis. 5. history of iv drug use, on methadone. 6. chronic lung disease. 7. status post tachy arrhythmia with hypotension. 8. history of pulmonary embolus/deep venous thrombosis. 9. hepatitis b. 10. hepatitis c. 11. cirrhosis. 12. splenomegaly. 13. anemia. 14. benign prostatic hypertrophy. 15. depression. 16. history of methicillin-resistant staphylococcus aureus and vancomycin-resistant enterococcus. 17. peptic ulcer disease. medications on discharge: 1. prilosec 20 mg p.o. 2. bactrim-ds 1 tablet every monday, wednesday and friday. 3. methadone 50 mg p.o. q.d. 4. valium 5 mg to 10 mg p.o. q.6h. p.r.n. 5. oxycodone one to two tablets q.4-6h. p.r.n. 6. coumadin 5 mg p.o. q.h.s. 7. aspirin. at the time of this dictation he had not been restarted on his captopril or on a beta blocker, but the hope that this will happen if his blood pressure can tolerate it. additional discharge medications will be dictated separately in a discharge summary addendum. condition at discharge: the patient was discharged in good condition. [**first name11 (name pattern1) 4283**] [**last name (namepattern4) 4284**], m.d. [**md number(1) 7551**] dictated by:[**last name (namepattern1) 29450**] medquist36 d: [**2178-2-12**] 17:09 t: [**2178-2-12**] 17:39 job#: [**job number 108127**]",1
132,"admission date: [**2146-1-18**] discharge date: [**2146-1-27**] date of birth: [**2114-6-20**] sex: f service: cardiothoracic allergies: tegretol / vicodin attending:[**first name3 (lf) 922**] chief complaint: shortness of breath major surgical or invasive procedure: [**2146-1-21**] aortic valve replacement (21mm st. [**male first name (un) 923**] mechanical), mitral valve replacement( [**street address(2) 44058**]. [**male first name (un) 923**] mechanical), tricuspid valve repair (32mm [**company 1543**] contour 3d ring), and patent foreman ovale closure) history of present illness: 31 year old female with history of mssa endocarditis in [**9-23**], seizures, depression, hepatitis c p/w fever. fevr started 2 days ago, highest temp has been 103 at home, and also low back pain. in addition she has felt palpitations at night along with shortness of breath. yesterday symptoms got works with nausea and vomiting, vomited x 5 which was nonbloody and yellow. mostly she has been eating soup and water, as she has had difficulty eating solid foods. she feels that her back pain is worsening as well from her chronic low back pain. . initially pt presented to [**hospital6 3105**] on [**2146-1-8**]. blood cultures were drawn, which are pending. she was started on vancomycin and gentamicin given concern for endocarditis. daptomycin was started in place of vancomycin for concern for vre on [**1-9**] as [**5-17**] blood cx pwere positive for likely enterococcus also per chart pt had an adverse reaction to vancomycin. cxr was concerning for infiltrate as well thought to be [**3-17**] septic emboli. tee was done and concern for vegetations on mitral and aortic valves on [**1-10**], also noted ot have 2+ ai and 2+ mr. mri of spine showed no e/o osteomyelitis. abx changed to gentamicin and ampicillin following [**5-17**] blood cx returned with enterococcus faecalis. id team was consulted regarding these recommendations. tte done on [**1-15**] showed vegetations on av and on mv, c/w tee results on [**1-10**]. cxr was done on [**1-15**] which showed rll infiltrate, cefepime was started but discontinued after ct chest showed no pna and bilateral pleural effusions concerning for chf thought to be [**3-17**] endocarditis. bnp was 508. pt transferred to [**hospital1 18**] for evaluation by cardiac surgery for surgical eval of valvular disease. . currently, pt complaining of mild back pain and abdominal pain, c/w pain that she had at osh resolving with percocet. no shortness of breath, nausea, or other complaints. . on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. she denies recent fevers, chills or rigors. she denies exertional buttock or calf pain. all of the other review of systems were negative. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. referred for surgical evaluation. past medical history: mssa endocarditis in [**9-23**] seizures x 3 years depression hepatitis c anemia ivdu social history: tobacco history: denies etoh: denies illicit drugs: endorses heroin use, last use 3 months ago herbal medications: denies lives alone, no sick contacts family history: adopted, family hx unknown physical exam: admission physical exam: 53 kg 61"" vs: 98.5 96/44 111 18 95% ra general: wdwn f in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 15 cm. cardiac: rrr, ii/vi systoilic and diastolic murmurs heard throughout, no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominal bruits. extremities: no c/c/e. no femoral bruits. picc line in place in l arm skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ pertinent results: labs: [**2146-1-25**] 03:52am blood wbc-8.2 rbc-3.33* hgb-9.1* hct-28.4* mcv-85 mch-27.3 mchc-32.1 rdw-16.8* plt ct-276# [**2146-1-24**] 04:49am blood wbc-9.9# rbc-3.10* hgb-8.6* hct-26.0* mcv-84 mch-27.8 mchc-33.1 rdw-17.0* plt ct-178 [**2146-1-23**] 03:56am blood wbc-21.4* rbc-3.60* hgb-9.8* hct-29.5* mcv-82 mch-27.3 mchc-33.3 rdw-16.9* plt ct-238 [**2146-1-25**] 03:52am blood pt-22.4* ptt-37.0* inr(pt)-2.1* [**2146-1-24**] 04:49am blood pt-15.0* inr(pt)-1.4* [**2146-1-23**] 03:56am blood pt-14.1* ptt-26.8 inr(pt)-1.3* [**2146-1-22**] 01:35am blood pt-13.4* ptt-31.2 inr(pt)-1.2* [**2146-1-25**] 03:52am blood glucose-96 urean-18 creat-0.6 na-141 k-4.5 cl-105 hco3-29 angap-12 [**2146-1-24**] 04:49am blood glucose-103* urean-16 creat-0.6 na-139 k-3.4 cl-99 hco3-33* angap-10 [**2146-1-23**] 03:56am blood glucose-117* urean-12 creat-0.7 na-135 k-4.9 cl-97 hco3-28 angap-15 [**2146-1-22**] 01:35am blood glucose-91 urean-10 creat-0.6 na-131* k-5.1 cl-99 hco3-26 angap-11 [**2146-1-19**] 04:28am blood wbc-8.9 rbc-3.79* hgb-9.5* hct-30.6* mcv-81* mch-25.0* mchc-31.0 rdw-14.5 plt ct-398 [**2146-1-19**] 04:28am blood pt-11.2 ptt-34.0 inr(pt)-1.0 [**2146-1-19**] 04:28am blood glucose-90 urean-12 creat-0.7 na-140 k-4.7 cl-103 hco3-29 angap-13 [**2146-1-20**] 06:11am blood alt-8 ast-13 ld(ldh)-191 alkphos-59 totbili-0.3 [**2146-1-19**] 04:28am blood calcium-9.0 phos-4.8* mg-2.3 [**2146-1-19**] 04:28am blood %hba1c-5.3 eag-105 [**2146-1-19**] 03:41pm blood genta-0.8* [**2146-1-27**] 05:43am blood hct-29.1* [**2146-1-27**] 05:43am blood pt-33.8* inr(pt)-3.3* [**2146-1-27**] 05:43am blood urean-13 creat-0.5 na-135 k-4.4 cl-101 abd ultrasound ([**1-19**]): findings: there is a large right and left pleural effusion identified. the hepatic architecture is unremarkable. no focal liver abnormality is identified. no biliary dilatation is seen and the common duct measures 0.6 cm. the portal vein is patent with hepatopetal flow. the gallbladder is normal. the pancreas is unremarkable. the spleen is borderline in size measuring 12.1 cm. no hydronephrosis is seen. the right kidney measures 11.8 cm and the left kidney measures 12.6 cm. the aorta is of normal caliber throughout. the visualized portion of the ivc is unremarkable. no ascites is seen in the abdomen. impression: 1. no findings to suggest a hepatic abscess. 2. bilateral pleural effusions. 3. no ascites. tee [**2146-1-21**]:conclusions (prelim) pre-bypass: the left atrium is moderately dilated. no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. a patent foramen ovale is present. a right-to-left shunt across the interatrial septum is seen at rest. the left ventricular cavity is moderately dilated. overall left ventricular systolic function is moderately depressed (lvef= xx %). the right ventricular cavity is mildly dilated with mild global free wall hypokinesis. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to xx cm from the incisors. there is a large vegetation on the aortic valve. no aortic valve abscess is seen. severe (4+) aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. there is a moderate-sized vegetation on the mitral valve. severe (4+) mitral regurgitation is seen. moderate [2+] tricuspid regurgitation is seen. there is no pericardial effusion. post cpb#1 1. improved left and right ventricular systolci function with background inotropic support (epinephrine) 2. bileaflet maechanical valves seen in mitral aortic position. well seated and stable with good lealflet excursion with mild valvular regurgitation jets (washing jets) 3. minimal gradients across the prosthetic valves in aortic and mitral position. 4. progressive worsening of trisuspid regurgitation (central) after separation from cpb with associated systolic reversal of hepatic venous flow. no lealfelt avulsion/restriction visualized, but necessitated re-institution of cpb. post cpb#2 1, annuloplqasty ring seen in the tricuspid position. good leaflet excursion and mnimal gradient, with trace trisuspid regurgitation. 2. no ther change. echo [**1-26**] left atrium: mild la enlargement. right atrium/interatrial septum: normal ra size. left ventricle: normal lv wall thickness and cavity size. mild regional lv systolic dysfunction. no resting lvot gradient. right ventricle: mildly dilated rv cavity. borderline normal rv systolic function. abnormal septal motion/position. aortic valve: bileaflet aortic valve prosthesis (avr). avr well seated, normal leaflet/disc motion and transvalvular gradients. [the amount of ar is normal for this avr.] mitral valve: bileaflet mitral valve prosthesis (mvr). tricuspid valve: tricuspid valve annuloplasty ring. moderate [2+] tr. pericardium: trivial/physiologic pericardial effusion. conclusions the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. there is mild regional left ventricular systolic dysfunction with septal hypokinesis. the right ventricular cavity is mildly dilated with borderline normal free wall function. there is abnormal septal motion/position. a bileaflet aortic valve prosthesis is present. the aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. [the amount of regurgitation present is normal for this prosthetic aortic valve.] a bileaflet mitral valve prosthesis is present. a tricuspid valve annuloplasty ring is present. moderate [2+] tricuspid regurgitation is seen. there is a trivial/physiologic pericardial effusion. impression: no significant pericardial effusion. normal lv cavity size with hypokinesis of the septum. the movement of the septum appears abnormal - probably due to a combination of hypokinesis and post-pericardiotomy. the right ventricle is borderline dilated and borderline hypodynamic. mitral and aortic mechanical prosthesis are functioning normall. there is moderate tricuspid regurgitation compared with the prior study (images reviewed) of [**2146-1-20**], the patient is post-op with avr, mvr and a tricuspid ring. ventricular function has improved, the amount of pericardial fluid has decreased. brief hospital course: she was admitted with enterococcus endocarditis sensitive to ampicillin and gentamicin. power picc was in place. her antibiotics started [**1-9**] and first negative blood cultures were on [**1-11**]. she had some dyspnea on exertion, and was requiring 2l-3 o2. ruq u/s demonstrates b/l pleural effusions (no abscesses). echo demonstrated severe 4+ aortic valve regurgitation, aortic veg and 3+ mr. [**first name (titles) **] [**last name (titles) 1834**] surgery with dr. [**last name (stitle) 914**] on [**1-21**] and was transferred to the cvicu in stable condition on epinephrine and propofol drips. she was extubated the following morning and epinephrine weaned off. she was transferred to the floor on pod #2 to began to work with physical therapy to increase strength and mobility. coumadin was started for mechanical valves and was bridged with heparin until she was anticoagulated for inr goal 3.0-3.5. the infectious disease team was consulted and recommended 6 weeks of ampicillin and gentamicin from [**2146-1-22**] for enterococcus. chest tubes and pacing wires removed per protocol. she continued to progress well. gentamicin peak and trough were checked to assure proper dosing. by pod 6 she was ambulating with assistance, her incisions were healing well and she was tolerating a full oral diet. it was felt that she was safe for transfer to [**hospital1 **] state hospital for continued antibiotics. medications on admission: home medications: depakote 250 mg daily zoloft 50 mg daily lexapro 20 mg daily . medications on transfer: depakote 250 mg daily acetaminophen 325 mg prn percocet q4h prn lactobacillis lovenox 40 mg daily ferrous sulfate 325 mg daily clotrimazole 1% cream gentamicin 70 mg/1.75 ml every 8 hrs ampicillin 2 gm q4h discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. ranitidine hcl 150 mg tablet sig: one (1) tablet po once a day. 3. acetaminophen 325 mg tablet sig: two (2) tablet po q4h (every 4 hours) as needed for pain. 4. divalproex 250 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po daily (daily). 5. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po daily (daily). 6. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 7. outpatient lab work labs q [**hospital1 766**] cbc with diff, lft, bun, cr, gent peak and gent trough, pt/inr labs qwed pt/inr labs qfriday pt/inr bun, cr gent peak and gent trough lab results to [**hospital **] clinic phone ([**telephone/fax (1) 4170**] office fax:([**telephone/fax (1) 1353**] 8. warfarin 1 mg tablet sig: goal inr 3-3.5 tablets po once a day: to check inr [**1-28**] in am for further dosing - had received between 2-6 mg see coumadin form . 9. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 10. ampicillin sodium 2 gram recon soln sig: two (2) recon soln injection q4h (every 4 hours): 2 gram q4h for 6 weeks [**1-22**] thru [**3-5**] follow up in [**hospital **] clinic prior to completion . 11. gentamicin 40 mg/ml solution sig: fifty (50) mg injection q8h (every 8 hours): 50 mg q8h next trough and peak on [**hospital **] [**1-31**] for 6 weeks [**1-22**] thru [**3-5**] follow up in [**hospital **] clinic prior to completion . 12. lexapro 20 mg tablet sig: one (1) tablet po once a day. 13. dilaudid 2 mg tablet sig: 1-2 tablets po every four (4) hours as needed for pain. discharge disposition: extended care facility: [**hospital1 **] discharge diagnosis: mssa endocarditis complicated by enterococcal endocarditis s/p avr/mvr/tv repair/pfo closure aortic valve regurgitation mitral valve regurgitation seizures hepatitis c ivdu depression anemia discharge condition: alert and oriented x3 nonfocal ambulating with steady gait incisional pain managed with dilaudid incisions: sternal - healing well, no erythema or drainage edema none discharge instructions: please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. look at your incisions daily for redness or drainage please no lotions, cream, powder, or ointments to incisions each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart no driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive no lifting more than 10 pounds for 10 weeks please call with any questions or concerns [**telephone/fax (1) 170**] females: please wear bra to reduce pulling on incision, avoid rubbing on lower edge **please call cardiac surgery office with any questions or concerns [**telephone/fax (1) 170**]. answering service will contact on call person during off hours** followup instructions: you are scheduled for the following appointments: surgeon: dr. [**last name (stitle) 914**] [**name (stitle) 766**] [**3-7**] at 1:00 pm, [**hospital ward name **] bldg, [**hospital unit name **] [**telephone/fax (1) 170**] cardiologist:dr. [**first name4 (namepattern1) **] [**last name (namepattern1) 3646**] [**2-18**] at 11:30 am 1-[**telephone/fax (1) 21903**] infectious disease with dr [**last name (stitle) **] [**telephone/fax (1) 457**] - please call to schedule for appointment in 4 weeks labs weekly - cbc with diff, lft - results to [**hospital **] clinic labs biweekly bun, cr, gent peak and trough - results to [**hospital **] clinic please call to schedule appointments with your primary care dr.[**last name (stitle) **] in [**5-18**] 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** labs: pt/inr for coumadin ?????? indication mechanical aortic and mitral valves goal inr 3-3.5 first draw friday [**1-28**] please check [**month/year (2) **], wednesday, and friday for 2 weeks then twice a week if inr and dosing stable rehab physician to manage coumadin until discharge from rehab **please arrange for coumadin/inr f/u prior to discharge from rehab* completed by:[**2146-1-27**]",1
133,"admission date: [**2101-5-21**] discharge date: [**2101-5-22**] date of birth: [**2057-11-8**] sex: f service: medicine allergies: penicillins / amoxicillin / e-mycin / latex / ondansetron / vancomycin / levofloxacin / zofran / phenergan / dilaudid / ceftriaxone / sulfamethoxazole/trimethoprim / voriconazole / fluconazole / caspofungin / doxycycline / propranolol / neurontin / azithromycin / xopenex hfa / optiray 300 / ketorolac attending:[**first name3 (lf) 5893**] chief complaint: doxycycline desensitization major surgical or invasive procedure: none history of present illness: [**known firstname **] [**known lastname 94828**] is a 43 yo female with a history of multiple drug allergies who presented to her pcp's office on [**5-9**] with diffuse joint aches and a history of a recent bull's eye rash. she reported that she had a rash on her left anterior shin for about 6 days prior to her visit with her pcp. [**name10 (nameis) **] took a picture of a rash and it was consistent with erythema migrans. she had had some exposure to the [**doctor last name 6641**] prior to the rash developing, but does not recall a tick bite. her pcp has not started treatment due to concern about her doxycycline allergy. she consulted with the patient's allergist at [**hospital1 112**] who recommended doxycycline desensitization and outlined a protocol. the patient's treatment has been delayed by lack of icu beds. she reports mild joint aches in her knees and elbows. her joint pain was quite severe earlier but has lessened over the past week. she describes some low-grade fevers, but no chills. denies joint swelling. of note, the patient recently was treated for pyelonephritis with gentamycin. . review of sytems: (+) per hpi and for night sweats r/t menopausal sx, intermittent headache and chronic constipation. (-) denies fever, chills, recent weight loss or gain. denies sinus tenderness, rhinorrhea or congestion. denied cough, shortness of breath. denied chest pain or tightness, palpitations. denied nausea, vomiting, diarrhea, abdominal pain. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias. past medical history: # multiple drug allergies including likely [**initials (namepattern4) 22721**] [**last name (namepattern4) **] syndrome associated with fluconazole desensitization. also, severe phlebitis with piccs, milder phlebitis with conventional iv catheters if left indwelling # cvid - monthly ivig # history of recurrent pyelonephritis # autonomic neuropathy - on ivig primarily for neuropathy but also cvid. # esophageal dysmotility # oral/genital ulcers ? behcet's # colonic inertia s/p subtotal colectomy at [**hospital3 14659**] in [**2093**] # atrophic vaginitis with recurrent yeast infections # sleep disorder characterized by non-rem narcolepsy, restless leg syndrome, and periodic leg movements social history: the patient was [**name initial (md) **] gi np at [**hospital1 18**]. she has been on disability for 2 years. she lives alone in the [**hospital3 4414**]. no tobacoo, alcohol and illict drugs. family history: mother with ovarian cancer and history of dvt. physical exam: general: alert, oriented, no acute distress, very pleasant. heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, + midline abdominal scar, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, no joint erythema or swelling. skin: no rashes pertinent results: [**2101-5-21**] 08:29pm blood wbc-4.0 rbc-3.89* hgb-12.1 hct-35.6* mcv-92 mch-31.0 mchc-33.9 rdw-12.1 plt ct-206 [**2101-5-21**] 08:29pm blood pt-11.7 ptt-22.7 inr(pt)-1.0 [**2101-5-21**] 08:29pm blood glucose-96 urean-13 creat-0.9 na-138 k-4.0 cl-102 hco3-31 angap-9 [**2101-5-21**] 08:29pm blood calcium-8.8 phos-3.9 mg-2.0 brief hospital course: 43 yo female with a history of cvid, multiple drug allergies, recurrent pyelonephritis, colonic inertia s/p colectomy, recurrent yeast vaginitis who presents for doxcycline desensitization after recent diagnosis of early lyme disease. she received pre-treatment with benadryl 25mg iv (over 30min) and famotidine 20mg iv. she successfully underwent the doxycycline infusion per desensitization protocol. she completed the infusion at 5am. she did not have any adverse reactions. she will start doxycycle as an outpatient at 5pm. the prescription has been provided to her already by her pcp. [**name10 (nameis) **] was instructed that the efficacy of her desensitization depends on maintaining a serum concentration of doxycycline and that if she misses a dose she is likely to get an allergic reaction. she was instructed to contact her pcp if she misses a dose. . she was continued on her home medications. of note, she has had a history of phlebitic reactions previously to iv catheters left in place for longer than a day. her iv was removed promptly. medications on admission: # epinephrine [epipen] 0.3 mg/0.3 ml (1:1,000) pen injector # esomeprazole magnesium [nexium] 40 mg po bid # ferumoxytol [feraheme] 510 mg/17 ml (30 mg/ml) solution infuse over one minute weekly for 2 weeks have patient stay in observation for 30 minutes after first dose - none recently # fexofenadine 60 mg tablet po tid - not using currently # lorazepam [ativan] 0.5 mg tablet po q6hr prn anxiety # methylphenidate [concerta] 18 mg tablet extended rel 24 hr 2 tab(s) by mouth once a day [**2101-4-25**] # sucralfate 1 gram tablet crushed and used topically four times a day compound and diluted to 4% into an ointment please make dye and fragrance free prn. discharge medications: 1. concerta 36 mg tablet extended rel 24 hr sig: one (1) tablet extended rel 24 hr po daily (). 2. epipen 0.3 mg/0.3 ml pen injector sig: one (1) injection intramuscular as needed as needed for anaphylaxis. 3. esomeprazole magnesium 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 4. ativan 0.5 mg tablet sig: one (1) tablet po every six (6) hours as needed for anxiety. 5. sucralfate 1 gram tablet sig: one (1) tablet po four times a day: crush tablet and use topically (diluted to 4% in an ointment). 6. doxycycline monohydrate 100 mg tablet sig: one (1) tablet po twice a day for 14 days. 7. [**doctor first name **] 60 mg tablet sig: one (1) tablet po three times a day as needed for allergy symptoms. discharge disposition: home discharge diagnosis: primary diagnosis lyme disease doxycycline allergy discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: thank you for allowing us to take part in your care. you were admitted to the hospital for desensitization of doxycycline. your outpatient physicians feel that you have lyme disease. therefore, it was important to give you doxycycline to treat this infection. you were exposed to doxycycline to help prevent an allergic reaction from taking place. you were monitored very closely in the icu and did not have any adverse reactions. we made no changes to your medications. please start taking doxycycline at home tonight at 5pm. please do not miss [**first name (titles) 691**] [**last name (titles) 11014**]. if you miss a dose, you are at risk of developing an allergic reaction. please contact your primary care doctor if you miss [**first name (titles) 691**] [**last name (titles) 4319**] of the doxycycline. followup instructions: you have the following appointments scheduled: provider: [**name10 (nameis) **] [**first name8 (namepattern2) 1243**] [**name8 (md) **], m.d. date/time:[**2101-5-23**] 11:20 provider: [**name10 (nameis) 1248**],chair two [**name10 (nameis) 1248**] rooms date/time:[**2101-5-27**] 10:15 provider: [**name10 (nameis) 706**] phone:[**telephone/fax (1) 327**] date/time:[**2101-6-6**] 3:30 completed by:[**2101-5-22**]",0
134,"admission date: [**2133-11-7**] discharge date: [**2133-11-17**] date of birth: [**2100-12-7**] sex: m service: medicine allergies: dapsone / bactrim ds attending:[**first name3 (lf) 562**] chief complaint: seizure major surgical or invasive procedure: none history of present illness: pateint is a 32 year old male with pmhx of hiv diagnosed 10 years ago and etoh abuse who presents with reported siezure witnessed by the patient's mother. [**name (ni) **] states that he used to drink [**6-8**] etoh drinks a day and stopped 2 weeks ago (however when he first came to the ed he was reported as stopping etoh use 2 days ago). he states that he was in his usual state of health when he fell from his sofa at 9:30am and was reported as having a seizure. patient hit his left shoulder when he fell. patient denies any focal deficits before seizure event. he denies any headache, vision problems, slurred speech, ataxia. he states that he does not remember the seizure event. he denies any incontinance. he was brought to the ed by ems where he was found to have a temp of 100.6 and tachycardic. patient [**name (ni) 60563**] scale was 18 and was given valium x 3. patient had head ct which was negative for any mass lesion and had an lp performed. csf was sent out for cell count with diff, gram stain, cryptococcus antigen. patient serum toxicology was negative. currently patient states that he feels very weak. he states that his muscles hurt, especially his abdominal muscle. it is difficult for him to sit up. he denies any numbness. patient denies any fever/chills; n/v prior to admission. he states that he does have diarrhea and has been having diarrhea for 5 years. patient states that his left shoulder is very painful. he had an xray of shoulder done in the ed which was negative for dislocation or fracture. patient denies any melena, brbpr, hematoemesis. patient has been off haart medication for 6 months. he can't remember his last viral load and thinks his last cd4 count was < 100 about 6 months ago. he states that he stopped haart because he had been on medications for 10 years and just got tired of taking meds. patient states that he has pcp x 3 in the past and has thrush. he denies any rashes or other illnesses related to his hiv except the diarrhea. past medical history: hiv 10 years ago anxiety history of seizure in the pst related to etoh use social history: etoh abuse [**6-8**] drinks per day; states he stopped 2 weeks ago denies any illicit drug use currently does not have any sexual partners no smoking history he lives with his mother and grandmother physical exam: pe: t 99.9 p 98 bp 131/81 r 19 o2sat 97% gen: [**last name (un) **] healthy looking male, who appears to be in mild discomfort secondary to pain heent: perrla, eomi, sclera anicteric, (+)thrush, no exudates neck: supple, no lad cardiac: rrr s1/s2 no murmurs lungs: cta b/l abd: soft, tender to deep palpation diffuse, no gaurding or rebound. nabs ext: no obvious deformities. patient unable to lift left shoulder due to pain. patient having difficulty lifting legs secondaryu to pain. no edema, rashes, cuts neuro: aaox3, cn ii-xii intact. exam limited secondary to pain. patient with 3/5 ms [**first name (titles) **] [**last name (titles) **] and [**3-6**] in le (however states that he is weak because of pain). sensory grossly intact. patient unable to perform rapid alternating movements and heel to shin [**2-2**] pain. finger to nose test intact. pertinent results: [**2133-11-7**] 11:10pm glucose-120* urea n-7 creat-0.7 sodium-137 potassium-3.0* chloride-101 total co2-28 anion gap-11 [**2133-11-7**] 05:51pm cerebrospinal fluid (csf) protein-47* glucose-74 [**2133-11-7**] 05:51pm cerebrospinal fluid (csf) wbc-3 rbc-1* polys-0 lymphs-98 monos-0 macrophag-2 [**2133-11-7**] 04:00pm urine hours-random [**2133-11-7**] 04:00pm urine gr hold-hold [**2133-11-7**] 04:00pm urine color-straw appear-clear sp [**last name (un) 155**]-1.005 [**2133-11-7**] 04:00pm urine blood-sm nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg [**2133-11-7**] 04:00pm urine rbc-0-2 wbc-0-2 bacteria-rare yeast-none epi-0-2 [**2133-11-7**] 01:15pm glucose-147* urea n-9 creat-0.7 sodium-135 potassium-2.7* chloride-93* total co2-26 anion gap-19 [**2133-11-7**] 01:15pm calcium-9.0 phosphate-1.1* magnesium-1.4* [**2133-11-7**] 01:15pm asa-neg ethanol-neg acetmnphn-neg bnzodzpn-neg barbitrt-neg tricyclic-neg [**2133-11-7**] 01:15pm wbc-2.5*# rbc-4.03* hgb-13.5* hct-37.0* mcv-92# mch-33.6*# mchc-36.6* rdw-12.8 [**2133-11-7**] 01:15pm neuts-50.2 lymphs-39.6 monos-9.4 eos-0.5 basos-0.2 [**2133-11-7**] 01:15pm plt smr-low plt count-99* [**2133-11-7**] 05:51pm cerebrospinal fluid (csf) wbc-3 rbc-1* polys-0 lymphs-98 monos-0 macroph-2 [**2133-11-7**] 05:51pm cerebrospinal fluid (csf) totprot-47* glucose-74 xray shoulder: left shoulder, 3 views, on [**2133-11-17**]: compared to [**2133-11-7**], there is a nondisplaced fracture through the lesser tuberosity of the left humeral head, best seen on the axillary view. no evidence for dislocation. ct head: impression: no evidence of intracranial hemorrhage or edema. [**month/day/year 4338**] head: there is mild prominence of sulci and ventricles inappropriate for patient's age. no evidence of midline shift mass effect or hydrocephalus is seen. there are no focal signal abnormalities seen. no evidence of acute infarct noted. mucosal thickening is seen in the left maxillary and ethmoid sinuses. brief hospital course: ## alcohol withdrawal - initially the differential diagnosis for patient's seizure consisted of etoh withdrawal, infection related to hiv such as toxoplasmosis or pml, or electrolyte abnormalitiy (very low phosphorus). patient's phosphorous was repleated and csf culture and fungal culture came back negative. csf came back negative for cryptococcus. once patient was sent to the floor on night of hd #1 he became extremely agitated, hallucinating with [**month/day/year 60563**] > 38. patient remained unresponsive to multiple doses of ativan, valium and haldol. patient was felt to be in dts and sent to the icu for close monitoring and aggressive benzodiazapine treatment. in the micu patient required > 700mg of valium. in micu patient remained somulaent and psychiatry was consulted to assist with benzo administration. psychiatry recommended valium taper and prn haldol for aggitation. patient remained in the icu for 5 days and when he was transferred back to the floor he was off the [**month/day/year 60563**] scale and written for prn haldol for agitation which he did not require. [**month/day/year 60563**] scale was restarted on the floor for an extra 24 hours to make sure patient truelly recovered from etoh withdrawal. while on the floor patient remained stable with no more evidence of etoh withdrawal. addiction service was consulted to counsel patient about etoh abuse and setup outpatient followup if needed. ## hiv - patient cd4 count came back as 122 and hiv vl was not processed. patient was not restarted haart therapy given patient's non-compliance and possible resistance. patient will follow up outpatient for re-assessment of haart medications before restarting. continued patient on fluconazole for thrush and restarted patient on bactrim ds 1 tab daily for pcp prophylaxis once cd4 count came back as 122. patient has history of bactrim allergy (gets a rash) that he has been desensitized too. patient has been off bactrim for a few months and some concern if he would now be sensitive to bactrim. however after further history taking patient has been on and off bactrim for many years without any adverse reactions so it was felt that it would be okay to restart bactrim and monitor closely for allergic reaction. ## rhabdomyolysis - in the icu patient also noted with rhabdomyolysis with ck > [**numeric identifier 890**] secondary to alcohol withdrawal. patient given aggressive iv hydration to prevent renal failure. ck, cre and bun were monitored daily and continued to trend down. patient showed no evidence of renal failure while in hospital. patient however remained weak and stiff after recovering from etoh withdrawal which could be expected given rhabdomyolysis. physical therapy was consulted to work with patient once he was on the floor. ## id - in the icu patient was found to have gram postive urinary tract infection and on hd # 5 was noted to have a temp of 103.4 (however temp ran elevated as baseline while patient was in dts) with cough. patient had a chest xray done which suggested a rll infilatrate and it was felt that patient had aspiration pneumonia. he was started on levofloxacin and flagyl. a repeat chest xray showed no evidence of pneumonia but patient kept on levofloxacin for uti. once on the floor patient was switched to clindamycin since levofloxacin can lower seizure threshold. a repeat pa&la chest xray was done once on the floor to assess if patient really had a pneumonia. however patient was kept on 10 day course of clindamycin given his uti. patient remained afebrile on the floor with normal wbc. once patient mental status improved it was not felt that he was an aspiration risk and did well on clear diet so he was advance to a regular diet. ## shoulder fracture - on admission patient had x-ray of shoulder which was negative for fracture or dislocation, however the axillary view was not clearly visualized. patient continued to have shoulder pain so a repeat x ray was done which showed a non-displaced fracture of the humeral head of the left shoulder. ortho was consulted who recommended that patient keep his arm in a sling and follow up outpatient with orthopedics. patient was setup for outpatient follow up. medications on admission: none - patient stopped taking haart and prophylaxis medication 6 months prior discharge medications: 1. fluconazole 100 mg tablet sig: one (1) tablet po q24h (every 24 hours). disp:*30 tablet(s)* refills:*2* 2. multivitamin capsule sig: one (1) cap po daily (daily). disp:*30 cap(s)* refills:*2* 3. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. trimethoprim-sulfamethoxazole 160-800 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 6. clindamycin hcl 150 mg capsule sig: two (2) capsule po q8h (every 8 hours) for 3 days. disp:*18 capsule(s)* refills:*0* 7. trazodone hcl 50 mg tablet sig: one (1) tablet po at bedtime as needed for insomnia. disp:*7 tablet(s)* refills:*0* 8. percocet 5-325 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for pain. disp:*50 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: alcohol withdrawal urinary tract infection rhabdomyolysis shoulder fracture discharge condition: stable - patient finishing course of antibiotics for pneumonia and will follow up outpatient for shoulder injury. discharge instructions: please go to scheduled [**numeric identifier 4338**] of shoulder on tuesday novemeber 23rd at 5:45pm on the [**hospital ward name 517**] in the clinical center building in the basement. please follow up with scheduled appointment with dr. [**last name (stitle) 2719**] on tuesday novemeber 30th at 3:20pm on the [**hospital ward name 516**] in the [**hospital ward name 23**] building please call day treatment as soon as you are able, to setup treatment please make sure you follow up with your primary care doctor outpatient to discuss restarting haart therapy. please continue to take medications as prescribed. you are being treated for urinary tract infection and pneumonia with antibiotics, please continue to take antibiotics for full 10 day course (3 more days). followup instructions: please make sure you follow up with your primary care doctor outpatient to discuss restarting haart therapy please call the day treatment center, number has been provided provider: [**name10 (nameis) 4338**] where: cc clinical center [**name10 (nameis) 4338**] phone:[**telephone/fax (1) 327**] date/time:[**2133-11-24**] 5:45pm provider: [**name10 (nameis) 8741**] [**name11 (nameis) **], md where: [**hospital6 29**] orthopedics phone:[**telephone/fax (1) 1228**] date/time:[**2133-12-1**] 3:20pm",0
135,"admission date: [**2153-3-19**] discharge date: [**2153-3-29**] date of birth: [**2089-5-11**] sex: m service: medicine allergies: no known allergies / adverse drug reactions attending:[**first name3 (lf) 5141**] chief complaint: gu bleed major surgical or invasive procedure: hemodialysis with temporary line paracentesis kidney biopsy history of present illness: 63-year-old male with hep c cirrhosis and hcc who was admitted for new arf (creatinine 11.9 up from 1.1 on [**3-8**], k max on day of admission was 6.2) after recently moving to [**location (un) 86**]. he started hd yesterday which he tolerated well and then underwent left renal biopsy today at 11:30. he got ddavp for plts of 65 in setting of liver failure. he then began having hematuria. from discussion with nursing over the course of the afternoon he may have had up to 660cc of frank looking blood out his foley. he never became tachycardic. he was seen by urology who began cbi. he was having bladder pain. he also received 200cc ivf with the plan to have it taken off by hd at a later time. during hd he dropped his sbp to 70s and hd was discontinued for labile pressures. yesterday during dialysis his sbp were only as low as 80s. he lives at a sbp of 90s per the patient. he never was tachycardic today. hct this am 39.8 this am and was 25.5 this afternoon. hct was 39.6 on arrival to the hospital but likely baseline is 30. he received the beginning of a blood transfusion on the floor but became hypothermic and developed rigors. blood transfusion was stopped. pt states blood always needs to be specially prepared for him. hct on arrival to the unit was 20.4. inr today was 1.4. . he has hcc [**2-14**] hepatitis c complicated by esophageal varices s/p banding, anemia requiring transfusion, portal gastropathy, and ascites requiring intermittent paracenteses. his most recent chemotherapy was from was sorafenib between the dates of [**2153-1-22**] and [**2153-3-6**]. he had stopped his chemo at that time due to an admission for a gi bleed. he had banding of a non actively bleeding variceal bleed at that time. . on arrival to the icu vitals were t95.8 sbp98/50 hr66 rr14 100% ra. the pt reported he was feeling much better. all bladder discomfort and rigors has resolved. past medical history: onc hx: -[**2150-11-19**]: resection of 4x4x3.8cm liver lesion in segment 5. pathology consistent with hcc. no lymphovascular invasion -[**2151-5-20**]: resection of 1.8cm lesion in segment 5 -[**2152-2-14**]: chemoembolization of a branch of right hepatic artery with taxotere and embospheres for two right lobe lesions measuring 1.5 and 0.5 cm along with microwave ablation of the 1.5cm lesion -had been on transplant list when mri [**2152-8-11**] showed 2.4 x 4.3cm lesion in segment 8 and thrombosis of a portal vein branch. underwent biopsy of the lesion which revealed a moderately differentiated hepatocellular carcinoma with tumor embolus in the portal vein branch. afp started rising, 232ng/ml. delisted from transplant list. -attempt to enroll in search trial. however, pt had anemia (despite d/c-ing internferon and ribavarin), making him ineligible from study -began radiation in [**11/2152**] and finished 01/[**2153**]. since [**2153-1-22**] he has been on sorafenib 400mg [**hospital1 **]. afp steadily increasing over last 5 months to 3000s. -required large volume paracentesis twice [**2-/2153**] (7.6l and 7.8l). episodes of anemia secondary to gi bleeding. egd and colonoscopy performed, revealing esophageal varices, hemorrhoids and mild portal gastropathy. -hospital admission [**2153-3-5**] for drop in hct for which he received prbcs. no site of bleeding identified. . other past medical history: htn ? chf social history: recently moved from [**state 531**] to [**location (un) 86**] to be near his son. lives alone but son lives ten minutes away. worked in the past as sheet metal worker but now retired. denies hx of smoking, etoh or illicit drug use, including iv drugs. family history: father: cirrhosis, etoh physical exam: exam on admission: vs: 95.5 88/50 60 20 100%ra gen: aox3, nad heent: perrl. mmm. no lad. no jvd. neck supple. no cervical, supraclavicular, or axillary lad cards: rrr s1/s2 normal. no murmurs/gallops/rubs. pulm: no dullness to percussion, ctab no crackles or wheezes abd: bs+, distended, moderate ascites, nt, no rebound/guarding, liver enlarged to 2cm below costal margin, no [**doctor last name 515**] sign extremities: wwp. 3+ b/l edema, l > r, left calf pain, dps, pts 2+. skin: no rashes or bruising neuro: cns ii-xii intact. 5/5 strength in u/l extremities. no asterixis exam on discharge: vs: 98.2 120/64 66 16 97%ra gen: aox3, nad heent: perrl. mmm. no lad. no jvd. no [**doctor first name **]. cards: rrr s1/s2 normal. no murmurs/gallops/rubs. pulm: no dullness to percussion, ctab no crackles or wheezes abd: bs+, distended, moderate ascites, nt, no rebound/guarding, liver enlarged 2cm below costal margin extremities: wwp. 2+ b/l edema, l > r skin: no rashes or bruising, anicteric neuro: cns ii-xii intact. 5/5 strength in u/l extremities. no asterixis. pertinent results: admission labs: [**2153-3-19**] 11:00am blood wbc-11.6* rbc-3.94* hgb-12.4* hct-39.6* mcv-100* mch-31.5 mchc-31.4 rdw-19.0* plt ct-113* [**2153-3-19**] 11:00am blood pt-17.6* inr(pt)-1.6* [**2153-3-19**] 11:00am blood gran ct-8810* [**2153-3-19**] 11:00am blood urean-141* creat-11.9* na-134 k-5.2* cl-101 hco3-16* angap-22* [**2153-3-19**] 11:00am blood alt-30 ast-65* ld(ldh)-170 alkphos-244* totbili-1.3 dirbili-0.8* indbili-0.5 [**2153-3-19**] 11:00am blood totprot-7.7 albumin-2.6* globuln-5.1* calcium-8.2* phos-11.8* mg-2.0 [**2153-3-19**] 11:00am blood afp-2802* [**2153-3-19**] 06:15pm blood c3-83* c4-15 [**2153-3-20**] 07:10am blood hcv ab-positive* discharge labs: [**2153-3-29**] 07:02am blood wbc-6.4 rbc-2.98* hgb-9.4* hct-29.0* mcv-97 mch-31.5 mchc-32.4 rdw-19.4* plt ct-95* [**2153-3-29**] 07:02am blood pt-13.5* ptt-30.8 inr(pt)-1.2* [**2153-3-25**] 05:50am blood lupus-neg [**2153-3-25**] 05:50am blood aca igg-pnd aca igm-pnd [**2153-3-29**] 07:02am blood glucose-92 urean-74* creat-2.9* na-135 k-4.2 cl-99 hco3-29 angap-11 [**2153-3-24**] 06:00am blood alt-24 ast-64* ld(ldh)-155 alkphos-183* totbili-1.5 [**2153-3-29**] 07:02am blood albumin-2.5* calcium-8.9 phos-4.6* mg-1.8 [**2153-3-21**] 06:00am blood hapto-120 [**2153-3-19**] 06:38pm blood cryoglb-positive * [**2153-3-20**] 07:10am blood hbsag-negative hbsab-positive hbcab-positive [**2153-3-19**] 06:15pm blood anca-negative b [**2153-3-19**] 06:15pm blood [**doctor first name **]-positive * titer-1:640 [**2153-3-19**] 06:15pm blood rheufac-<3 [**2153-3-19**] 11:00am blood afp-2802* [**2153-3-19**] 06:15pm blood pep-polyclonal [**2153-3-28**] 10:36am blood c3-97 c4-17 [**2153-3-27**] 06:44pm blood free kappa and lambda, with k/l ratio-pnd [**2153-3-19**] 02:19pm urine u-pep-multiple p ife-no monoclo osmolal-378 [**2153-3-19**] 02:19pm urine hours-random creat-198 na-40 k-31 cl-14 totprot-44 prot/cr-0.2 [**2153-3-26**] 03:53pm ascites wbc-50* rbc-52* polys-11* lymphs-13* monos-68* mesothe-8* [**2153-3-26**] 03:53pm ascites totpro-0.9 glucose-125 ld(ldh)-27 albumin-less than microbiology: urine culture (final [**2153-3-20**]): no growth. blood culture, routine (final [**2153-3-25**]): no growth. blood culture, routine (final [**2153-3-27**]): no growth. mrsa screen (final [**2153-3-24**]): no mrsa isolated. [**2153-3-26**] 3:53 pm peritoneal fluid gram stain (final [**2153-3-26**]): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final [**2153-3-29**]): no growth. anaerobic culture (preliminary): no growth. studies: [**2153-3-19**] gu u/s: impression: 1. normal kidneys. 2. enlarged prostate gland with calculated volume of 37.4cc. 3. large volume intra-abdominal ascites. [**2153-3-20**] bilateral lenis: impression: bilateral normal lower extremity us. negative for above-knee dvt bilaterally. [**2153-3-22**] ct abdomen/pelvis: impression: 1. mild perinephric stranding adjacent to the left kidney, most likely from recent percutaneous biopsy. a small hyperdense focus in the posterior aspect of the left kidney likely represents a tiny hematoma. 2. hyperdense blood within the left collecting system, including the proximal ureter, with no evidence of obstruction. there is a large amount of blood and clot within the bladder. there is no large hematoma outside of the collecting system. 3. massive abdominal ascites. 4. multiple irregular hypodensities within the liver, incompletely characterized on this non-contrast enhanced study, compatible with multifocal hcc, better seen on prior reference imaging studies. 5. mediastinal and porta hepatis lymphadenopathy. 6. colonic diverticulosis. [**2153-3-21**] kidney biopsy: ultrasound guidance for renal biopsy by nephrologist: ultrasound examination of the kidneys was performed. the lower pole of the left kidney was identified and the position was marked on the patient's back for renal biopsy to be performed by the nephrologist. [**2153-3-21**] cxr: opacification in infrahilar right lung is probably atelectasis, unchanged. there are no findings to suggest current pneumonia. heart size is normal. no pleural abnormality. right jugular line ends in the region of the superior cavoatrial junction. [**2153-3-26**] peritoneal fluid: negative for malignant cells. [**2153-3-26**] paracentesis: impression: successful ultrasound-guided diagnostic and therapeutic paracentesis of 3 liters of serous fluid. [**2153-3-27**] ct abdomen/pelvis: impression: 1. unchanged hyperdense focus in the posterior left kidney, consistent with a small subcapsular hematoma. 2. decreased amount of hyperdense blood and clot both within the proximal left collecting system and the bladder. no hematoma is seen outside of the collecting system. 3. large amount of abdominal ascites. 4. incompletely characterized irregular hypodensities within the liver consistent with the patient's known multifocal hcc. brief hospital course: 63-year-old male with hep c cirrhosis and hcc with new onset acute renal failure and transferred to the unit for gu bleed after left renal biopsy. # acute renal failure: cr was elevated on admission to 11.9 from baseline 0.9. renal was consulted and advised dialysis as well as a kidney biopsy. he received several sessions of bedside hemodialysis; two sessions were prematurely stopped as his blood pressure did not tolerate it. cr came down to 4.2 following dialysis and further trended down to 2.9 prior to discharge. his lasix was held given his acute renal failure and hypotension. his other antihypertensives, amlodipine and aldactone, were also held. renal ultrasound showed enlarged prostate and large amount of ascites but normal kidneys. initially, it was felt that his acute renal failure was secondary to sorafenib induced nephrotoxicity. however, the kidney biopsy light microscopy showed mesangial proliferative gn. immunofluorescence showed 2+ igg and 2+ lambda mesangial deposition. there were no thrombi in the microvasculature to make deifinite diagnosis of a tma to implicate the sorafenib. spep showed polyclonal hypergammaglobulinemia and upep showed no monoclonal ig and was negative for bence [**doctor last name 49**] proteins. the serum free light chain assay was pending on discharge. [**country 7018**] red was negative for amyloid. his [**doctor first name **] was also positive at 1:640, lupus anticoagulant was negative, and anti-cardiolipin igg/m were pending at discharge. preliminary biopsy results were suspicious for fibrillary glomerulonephritis. he was discharged with follow-up at nephrology clinic for further evaluation as outpatient. he was discharged on sevelamer for hyerphosphatemia. he was also restarted on his lasix as cr stabilized. # gu bleed s/p kidney biopsy: pt underwent kidney biopsy on [**2153-3-21**] that was complicated by gross hematuria. he was seen by urology and put on cbi. his hematuria led to drop in hct from high 20s to low 20s and a drop in blood pressure to systolic 70s. he was transferred to the icu for the hypotension. ct abdomen showed perinephric stranding adjacent to the left kidney, most likely from recent percutaneous biopsy, a small hematoma in left kidney, and blood in the collecting system and bladder. he required a total of 5 units prbcs and 1 bag platelets throughout hospital admission. hct was stable at baseline in high 20s by time of discharge. repeat ct abdomen showed that small hematoma in kidney was stable. he no longer had hematuria at discharge and was able to urinate without a foley. # ?transfusion reaction: of note, pt exhibited rigors during his first transfusion. he was not febrile. per transfusion medicine, this was likely not a febrile non-hemoltyic transfusion reaction given the short duration of his symptoms, no subsequent fever and that leukoreduction significantly decreases the risk of these reactions. he experienced no adverse reactions from his subsequent transfusions. # hypotension: bp at admission was systolic 80s. he was given iv fluids and his antihypertensives and diuretics were held (with the exception of nadolol). he later became hypotensive to systolic 70s following hematuria after a kidney biopsy and hemodialysis. pt also with mild hyperthermia to 95 concerning also for infection on admission. he was pan-cultured, with negative urine and blood cultures. patient started on ctx 2gm q24hrs x2 days for possible sbp, but was dicscontinued [**3-23**] as likelihood of sbp felt to be very small with no abdominal pain, normal wbc and no fevers. peritoneal fluid showed no signs of infection. following transfusion of prbcs and iv fluids, bp stabilized in systolic 100s-120s throughout remainder of admission. # le edema: pt presented with le edema, left worse than right. on admission he endorsed some calf pain as well. b/l lenis were obtained, which were negative for dvt. pain resolved and pt was able to ambulate without difficulty. he was discharged back on his lasix. # hepatocellular carcinoma: pt was s/p sorafenib [**2153-1-22**] to [**2153-3-6**]. he has recently transferred his onc care here. he was continued on nadolol at admission but this was briefly held in the icu when gi bleed was being ruled out for drop in hct. he underwent a therapeutic paracentesis on [**2153-3-26**]; peritoneal fluid was benign and 3l were removed from abdomen. he will discuss with his outpatient oncologist whether sorafenib can be restarted once kidney function stabilizes. medications on admission: 1. oxycodone 5mg po q4h prn 2. aldactone 100mg po daily 3. lasix 40mg po daily 4. nadolol 20mg daily 5. protonix 40mg daily 6. amlodipine/benzapril 10/40 7. nexavar (on hold) 8. levaquin 500mg po x 1 week discharge medications: 1. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 2. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 3. nadolol 20 mg tablet sig: one (1) tablet po daily (daily). 4. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 5. sevelamer carbonate 800 mg tablet sig: one (1) tablet po tid w/meals (3 times a day with meals). disp:*90 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary: acute renal failure secondary: hepatocellular carcinoma discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure taking care of you in the hospital. you were admitted with acute kidney failure. the severity of your kidney failure required several sessions of hemodialysis. your kidney function improved with the hemodialysis. you were evaluated by our renal consult team who performed a kidney biopsy. this was complicated by bleeding that caused your blood counts to drop and your blood pressure to drop. you were transferred to the intensive care unit briefly because of this and were transfused with blood products. your blood pressure recovered and the bleeding in the urine stopped. your kidney biopsy showed a rare condition called fibrillary glomerulonephritis. it is very important that you have regular follow-ups at the [**hospital 10701**] clinic for frequent monitoring of your kidney function and possibly further testing. the following medications were changed: 1) stop amlodipine/benzapril unless one of your outpatient doctors wants to restart. your blood pressure was extremely good in the hospital so you didn't need it on discharge. 2) stop aldactone. ask your outpatient doctors when [**name5 (ptitle) **] [**name5 (ptitle) **] restart this medication. 3) stop levaquin 4) stop nexavar 5) start sevelemar 800mg three times a day with meals to lower your phosphorous levels followup instructions: you have the following appointments scheduled for you. you will need to come to the [**hospital 2793**] clinic on the [**location (un) 448**] of the [**hospital ward name 121**] building ([**hospital ward name **]) on monday [**2153-4-2**] to get your labs drawn. please come between the hours of 9am and 2pm and bring with you the lab order slip. department: hematology/oncology when: friday [**2153-4-6**] at 3:30 pm with: [**last name (lf) 3150**],[**name8 (md) **] md [**telephone/fax (1) 11133**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) 24**] campus: east best parking: [**hospital ward name 23**] garage department: west [**hospital 2002**] clinic when: wednesday [**2153-4-4**] at 2:30 pm with: [**first name8 (namepattern2) **] [**last name (namepattern1) **] [**name8 (md) **], 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 completed by:[**2153-3-29**]",0
136,"admission date: [**2126-7-29**] discharge date: [**2126-8-22**] service: chief complaint: dark urine and painful skin lesions. history of present illness: the patient is a 78-year-old male with a past medical history significant for myelodysplastic syndrome diagnosed eight years ago and multiple basal cell carcinomas who presented with a 3-day history of dark red/bloody urine. the patient also complained of a painful skin lesion on the left flank. regarding the hematuria, the patient reported painless hematuria with urine that was essentially dark red and never grossly bloody times one week. he denied any history of trauma as well as any dysuria, increased urinary frequency, hesitancy, or difficulty voiding. he also denied abdominal pain. the patient denied bright red blood per rectum, melena, hematemesis, hemoptysis, or epistaxis. he did admit to easy bruising and prolonged time to clot. the patient reported that his myelodysplastic syndrome had been stable until the spring of this year when he started to feel very tired and lethargic. he had started receiving weekly packed red blood cell transfusions seven weeks prior to admission and had started weekly epogen injections three weeks prior to admission. the patient was status post a bone marrow biopsy on [**2126-6-18**] that showed decreased erythroid elements with occasional dysplastic forms and decreased myeloid elements with limited maturation. however, there was no evidence of progression to acute leukemia. regarding the skin lesions, the patient reports that the left flank lesion first appeared three to four weeks prior to admission and that over the past week it had become increasingly tender. he says the lesion started out looking like a blister and then ""popped."" the patient is unsure of the nature of the fluid that it drained. the patient also has a left axillary lesion which he says started out like a blister and has been present for three to four days prior to admission. in the emergency department, the patient received one dose of gentamicin and oxacillin. he was also transfused with 2 units of packed red blood cells and 1 unit of fresh frozen plasma. he was also given potassium chloride. past medical history: 1. myelodysplastic syndrome diagnosed eight years ago; recently transfusion dependent. 2. gout. 3. basal cell carcinoma. 4. squamous cell carcinoma. 5. question history of inferior wall myocardial infarction. past surgical history: mohs surgery for basal cell carcinoma. social history: the patient is a former psychologist at [**hospital 14852**]. he is separated from his wife of 14 years. he has seven children. he drinks occasional alcohol. he has a 50 plus year history of cigar smoking and quit six to seven months ago. family history: his family history is significant for a daughter with diabetes. he had a brother who died of leukemia at the age of three and father who died of heart disease. medications on admission: his medications included epogen 20,000 units every tuesday, colchicine as needed, multivitamin with iron, and tylenol as needed. allergies: he has no known drug allergies. physical examination on presentation: the patient's vital signs on presentation were as follows; temperature was 100.6, heart rate was 88, respiratory rate was 24, blood pressure was 107/63, oxygen saturation was 97% on 2 liters. the patient's physical examination on presentation was as follows; in general, he was a pale-appearing elderly male. he was in no apparent distress. his head, eyes, ears, nose, and throat examination revealed sclerae were anicteric. his conjunctivae were pale. his oropharynx was clear. there was no thyromegaly, and no cervical lymphadenopathy, and no jugular venous distention. his lungs revealed bibasilar crackles. his heart examination revealed a regular rate and rhythm with a 2/6 systolic murmur. his abdomen was soft and nontender, with positive bowel sounds. he also had a palpable spleen tip. his back revealed no costovertebral angle tenderness. on his skin were multiple facial telangiectasias. his nose appeared slightly disfigured which was consistent with prior mohr surgery. he had multiple pink plaques, some with overlying scales distributed overlying scale distributed over his back, arms, and legs bilaterally. on his left flank was a well demarcated 7-cm to 8-cm indurated pink plaque with an area of central necrosis. he had a similar-appearing 5-cm to 6-cm pink plaque under his left axilla which; both of which were extremely tenderness to palpation. neurologically, he was alert and oriented times three. he had no focal deficits. his rectal examination revealed occult-blood positive brown stool. pertinent laboratory data on presentation: his laboratories on admission were as follows; complete blood count revealed a white blood cell count of 3.9, his hematocrit was 19.8, with a mean cell volume of 87. of note, the patient had a hematocrit of 25.8 three days prior to admission. his platelet count was 15. the differential of his white blood cell count was as follows; 27% polys, no bands, and 51% lymphocytes. his chemistry-7 was as follows; sodium was 132, potassium was 2.7, chloride was 98, bicarbonate was 22, blood urea nitrogen was 30, creatinine was 1.4, and blood glucose was 105. the patient's baseline creatinine is 1.1 to 1.2. the patient's coagulations were as follows; pt was 15.2, ptt was 41.9, inr was 1.6. the patient had a reticulocyte count that was sent in the emergency department and came back at 0.7. his urinalysis revealed brown cloudy urine, with large blood; it was nitrite positive, protein was greater than 300, glucose was negative, ketones were trace, there was a small amount of bilirubin, a moderate amount of leukocyte esterase; his red blood cell count was greater than 1000 with 3 to 5 white blood cells and many bacteria. there was also occasional uric acid crystals noted. blood cultures and urine cultures were sent from the emergency department on [**7-29**] which were negative. hospital course: the [**hospital 228**] hospital course related chronologically was as follows. on the evening of [**7-29**], he was admitted to the cc seven. he was initially treated with dicloxacillin for his skin lesions and started on intravenous ciprofloxacin for question pyelonephritis given the infectious-appearing urinalysis. it was unclear whether the patient's presentation with pancytopenia was secondary to blasts crisis; although, this was felt to be unlikely given that he has had a recent bone marrow biopsy which was negative for blasts, and his peripheral smear was also negative for blasts. his coagulopathy was treated with transfusions of fresh frozen plasma and vitamin k. on [**7-30**], the patient was seen by his outpatient hematologist who questioned whether the patient's skin lesions and hematuria could be secondary to septic emboli. the patient was ordered to get a transthoracic echocardiogram which he refused on several occasions. his antibiotics were also changed from dicloxacillin to oxacillin. on [**7-31**], the patient's coagulations were all evaluated despite vitamin k, and there was noted to be minimal correction of the anemia and thrombocytopenia despite transfusions. a disseminated intravascular coagulation screen was sent off and found to be positive. a dermatology consultation was also called on this day for help in evaluating the skin lesions. they felt that the lesions were most consistent with a neutrophilic dermatosis such as pyodermic gangrenosum versus sweet's disease which has a high incidence in myelodysplastic syndrome. also on the differential diagnosis was exanthematic gangrenosum due to pseudomonas infection as well as a deep fungal infection and cutaneous leukemia/lymphoma. the left axillary lesion was biopsied and sent for bacterial, and fungal, and atypical mycobacterial cultures. the dermatology consultation agreed with intravenous antibiotics. on [**8-1**], the patient was felt to be functionally neutropenic; and given the question of pseudomonas infection, he was started on intravenous ceftazidime. he was also continued on intravenous oxacillin. the infectious disease service was consulted regarding the disseminated intravascular coagulation and choice of antibiotics. they agreed with ongoing ceftazidime and oxacillin. on their differential was bacterial infections; namely furunculosis or xanthomatous granulosum. they also considered sporotrichum infections, mycobacterial infections, tick-borne diseases. they also considered sweet's disease in malignancy associated conditions. they recommended a ct of the abdomen if the workup was unrevealing. a renal ultrasound was also performed on [**8-1**] which showed multiple stones in the collecting system, but no evidence of hydronephrosis or renal abscess. on [**8-2**], the patient's skin biopsy gram stain revealed 2+ polys and no organisms, and the aerobic culture grew out coagulase-positive staphylococcus. at that point, it was decided to treat the patient for 10 days with intravenous oxacillin. the preliminary pathology report on the skin biopsy was as follows; clusters of plasma cells with infiltrative lymphocytes and neutrophils. on the differential was pyoderma versus infection versus plasma cell neoplasm. on [**8-3**], a serum protein electrophoresis and urine protein electrophoresis; which had been sent out earlier in the week, came back positive for monoclonal spike in the spep and two abnormal bands on the upep. a monoclonal intact immunoglobulin g lambda and monoclonal free lambda ([**initials (namepattern5) **] [**last name (namepattern5) **]-[**doctor last name **]). these results were discussed with the patient's outpatient hematologist who agreed with consulting the inpatient hematology service. the hematology service recommended starting the patient on decadron but holding off on melphalan. they said that overall, the association between myelodysplastic syndrome and multiple myeloma is not known, but they felt that people with malignancy and myeloma could develop severe disseminated intravascular coagulation which was consistent with the patient's clinical picture. on [**8-4**], the patient had a ct of the abdomen, chest, and pelvis to look for sources of occult infection. the ct of the chest was significant for a 1.2-cm nodule in the right upper lung adjacent to the major fissure. the ct of the abdomen and pelvis revealed a 1.2-cm cyst in the body of the pancreas. there was no lymphadenopathy that was noted in the mediastinum, in the axilla, or in the pelvis. on [**8-6**], the patient's diagnosis of myeloma was questioned by dr. [**last name (stitle) 2539**] (who was the patient's outpatient hematologist), and it was felt that the monoclonal spike most likely represented myoclonal gammopathy of unknown significance rather than myeloma. at that point, the steroids were discontinued, and the decision was made to repeat the skin biopsy given the questionable read of plasmacytoma. in the meantime, the infectious disease workup continued; and [**doctor last name 3271**]-[**doctor last name **] virus, cytomegalovirus, cryptococcal, and coccidia serologies were checked; which all came back as negative. also, babesia thick and thin smears were checked given a history of transfusions. on [**8-7**], the ceftazidime was discontinued after eight days secondary to no known organisms. the patient developed increasing transfusion dependence. previously, he had only required transfusions prior to procedure. at this point, he required transfusions to stop bleeding from his intravenous sites and from his biopsy sites. on [**8-8**], the patient had frank bleeding from his skin biopsy site that required two hours of manual pressure and resuturing to achieve hemostasis. also, the issues of access were raised given that the patient had only one peripheral intravenous line and was in need of multiple blood products. at that point, a peripherally inserted central catheter line was placed in interventional radiology. also, on the evening of [**8-8**], the patient had an adverse reaction while getting transfused with cryoprecipitate. on [**8-9**], the patient had a repeat bone marrow aspiration and biopsy. at that point, it was felt that given that the skin biopsies were nondiagnostic that the question of whether the patient was transforming into an acute leukemia needed to be readdressed. this bone marrow biopsy returned the week later and was consistent with myelodysplastic syndrome with no evidence of acute leukemia. subsequently, from [**8-9**] to [**8-15**], the patient continued to require aggressive blood product support through his disseminated intravascular coagulation with daily transfusions of platelets, packed red blood cells, cryoprecipitate, and fresh frozen plasma. disseminated intravascular coagulation laboratories were checked twice a day, and factors and cells were replaced liberally as the patient continued to ooze through his peripherally inserted central catheter site and biopsy sites. on [**8-14**], the patient became acutely hypotensive with a systolic blood pressure in the 90s. he was also symptomatic and complaining of lightheadedness. the patient was boluses with fluids and received blood products with a return of his blood pressure to the 140s. he had a repeat episode on [**8-16**], to which he again responded to fluids and blood products. on [**8-15**], the patient's repeat skin biopsy was read as consistent with intracellular organisms. toxoplasmosis stains done were positive, and the diagnosis of cutaneous toxoplasmosis was made with a question of toxoplasma-induced disseminated intravascular coagulation. on [**8-16**], the patient was started on medications for toxoplasmosis consisting of sulfadiazine, pyrimethamine, and folinic acid. he was also started on g-csf given his profound neutropenia and the possibility of a granulocytosis with a sulfa regimen. multiple urine cultures from [**8-14**] to [**8-16**] were positive for enterococcus. the infectious disease consultants felt that this was most likely a contaminant and was not initially treated. however, on [**8-16**], the patient was started on vancomycin for an enterococcus urinary tract infection. on the morning of [**8-17**], the patient had multiple sets of blood cultures which came back positive as gram-positive cocci in pairs and clusters. he had also been spiking fevers, and this was felt to be secondary to staphylococcus bacteremia. the patient was maintained on his toxoplasmosis medications as well as vancomycin. he was also on flagyl at this point for stools positive for clostridium difficile. on the evening of [**8-17**], the patient complained of [**4-12**] chest pain. the night float intern was called to see the patient, and an electrocardiogram was checked which was unchanged. his chest pain was treated with sublingual nitroglycerin, morphine, and ativan. several hours later, the patient again complained of chest pain, and at this time was markedly tachypneic with a respiratory rate in the 30s and a heart rate in the 100s. a blood gas was checked at this time which revealed a respiratory alkalosis with a large aa gradient. there was concern that the patient may have had a pulmonary embolism. an electrocardiogram was checked which showed ischemic changes across the precordium as well as in the lateral leads. troponin were cycled and found to be elevated. on examination, the patient was found to be in an irregular rhythm. an electrocardiogram was again checked, and that showed that the patient was in atrial fibrillation. he had previously, throughout the course of the admission, been in a normal sinus rhythm. the patient was also tachycardic to the 180s and was given intravenous diltiazem with minimal effect. the medical intensive care unit service was consulted and recommended cardioversion with amiodarone. however, the amiodarone could not be administered on the floor, and the patient required transfer to the medical intensive care unit for cardioversion. in the intensive care unit, on amiodarone, the patient did cardioverted back to sinus rhythm. he was also placed with a femoral line given that his peripherally inserted central catheter line was infected and felt to be the source of his staphylococcus bacteremia. on the evening of [**8-19**], the patient was transferred back from the medical intensive care unit to the floor initially in sinus rhythm; however, the patient converted back to atrial fibrillation shortly thereafter. on the following day, the sensitivities of the patient's blood cultures revealed the organisms were resistant to oxacillin, and the patient was continued on vancomycin. it was noted that his disseminated intravascular coagulation appeared to be stabilized. the patient was requiring fewer blood transfusions and was maintaining his counts for longer periods of time status post transfusions. however, it was notable that from a mental status standpoint, the patient was becoming quite frustrated with the number of complications that he was facing and was increasingly less optimistic about his prognosis. previously during the admission, in fact it was on [**8-16**], the patient; in consultation with his son and with his attending, decided on a do not resuscitate/do not intubate code status. this was later changed to comfort measures only on [**2126-8-21**]. his house officer, his attending, and his consultants related the fact that while his overall prognosis was poor, that he was actually showing signs of improvement regarding his disseminated intravascular coagulation and his staphylococcus infection. however, while the patient expressed a clear understanding of this, he wanted to continue with his decision to be comfort measures only. at that point, all intravenous fluids, medications, blood draws, and blood product support were withdrawn. he was ordered for intravenous morphine as needed, and for intravenous ativan, and valium as needed. social work and the palliative care service were involved with helping the patient deal with this decision and helping the family also cope with the imminent loss of their father. note: there will be an addendum that will be added at a later date. [**first name11 (name pattern1) 312**] [**initials (namepattern4) **] [**last name (namepattern4) 313**], m.d. [**md number(1) 314**] dictated by:[**name8 (md) 9130**] medquist36 d: [**2126-8-22**] 23:08 t: [**2126-8-28**] 12:02 job#: [**job number 23730**]",1
137,"admission date: [**2116-3-2**] discharge date: [**2116-3-7**] service: cardiology chief complaint: atrial flutter history of present illness: this 81-year-old male with cad, status post porcine avr and mvr, presented with atrial flutter. he presented to his outpatient urology appointment for bladder stones and was found to have a rapid heart rate in the 150's. ekg showed borderline complex tachycardia at 150. he was sent to see his cardiologist, dr. [**last name (stitle) 696**]. he saw dr. [**last name (stitle) 73**] in his place who performed cardiac sinus massage, and the patient was found to be in atrial flutter. he denied palpitations. no chest pain, shortness of breath, light-headedness, headache, or visual changes. past medical history: cad with lima to lad in [**2106**]. catheterization on [**2116-1-6**] showed significant restenosis of the lad that was status post ptca with moderate restenosis of the circumflex. reintervention on the lad was deferred due to gross hematuria. echocardiogram in 8/00 showed the left atrium to be moderately dilated. the lv cavity size was normal. severe regional lv systolic dysfunction. right ventricular chamber size and systolic function were normal. bioprosthetic aortic and mitral valves were seen. no aortic regurgitation. mild mitral regurgitation. ejection fraction was 25%. paroxysmal atrial fibrillation in 1/00, asymptomatic. treatment with beta blocker has caused sinus pauses and severe bradycardia in the past. adult-onset diabetes and bladder stones. admission medications: aspirin 325 mg, q day; digoxin 0.125 mg, q.o.d.; glyburide 2.5 mg, q.d.; isordil 10 mg, t.i.d.; lipitor 10 mg, q.d.; norvasc 5 mg, q.d.; and zantac 150 mg, po, b.i.d. allergies: shellfish physical examination: temperature 96.9; heart rate 120; blood pressure 120/70; respiratory rate 18. in general, he was in no acute distress. heent: pupils were 2 mm and symmetric. extraocular movements were intact. there was sustained nystagmus on the right lateral gaze. there was a left facial droop. neck: supple; no lymphadenopathy; carotids without bruits. respiratory: crackles one-third posteriorly bilaterally. cardiovascular: regularly irregular; i/vi systolic murmur at the apex. abdomen: soft; nontender; nondistended; positive bowel sounds. extremities: no edema; 1+ dp bilaterally. neuro: alert; conversive. strength: [**6-13**]. reflexes: 2+ biceps symmetric. laboratory studies: white count 8.6; hematocrit 42.3; platelets 229. pt 25.7; inr 1.3. sodium was 131, potassium was 3.8, chloride was 103, bicarbonate was 25, bun was 20, creatinine was 0.9, glucose was 149, calcium was 9.3, phosphorus was 2.4, and magnesium was 2.1. chest x-ray showed mild upper zone redistribution. ekg revealed wide-complex tachycardia at 150 with a left axis and left bundle branch block. hospital course: this 81-year-old male with cad, status post porcine avr and mvr, presented with atrial flutter. upon presentation, his heart rate was in the 130's. he received 5 mg of iv lopressor, and his heart rate went down to the 80's and 90's. he was started on lopressor 12.5 mg, po, t.i.d. for rate control. he was continued on digoxin at 0.125 mg, po, q.o.d. his digoxin level was 0.3. he was on this low dose because apparently he had high levels of digoxin in the past. the patient tolerated this rate control well with a heart rate in the 60's. the patient was also anticoagulated with heparin after a discussion with dr. [**last name (stitle) 986**], his urologist. apparently, in his recent admission in 11/00 when he had a cardiac catheterization, he had heavy hematuria; however, this was on heparin. lad intervention had been deferred at that point. the decision had been made to medically manage him. he tolerated the heparin and coumadin without any evidence of hematuria. the patient was also started on captopril given his low ejection fraction. it was anticipated that the patient would be discharged to home for chemical or electrical cardioversion after a month of anticoagulation. however, on telemetry, he was noted to have two five-beat runs of nonsustained ventricular tachycardia that were asymptomatic. he was taken to ep study. at ep study, the patient was noted to be quite agitated, requiring anesthesia to intubate the patient and a brief stay in the ccu. it was thought that the agitation was possibly secondary to the fentanyl that he received for anesthesia prior to the ep study. it may have been an adverse reaction, so the intubation was for airway protection. the plans for the ep study were for atrial flutter ablation as well as possible icd placement. however, given his agitation requiring five people to hold him down, the atrial flutter ablation was deferred and an icd was implanted. the patient was also started on amiodarone. on the day of discharge, the patient had been paced out of atrial flutter. he is to follow up with dr. [**last name (stitle) 696**] and dr. [**last name (stitle) 2450**] as well as the [**hospital 3941**] clinic. discharge diagnoses: 1. atrial flutter 2. nonsustained ventricular tachycardia, status post implantable cardiac defibrillator placement discharge medications: 1. amiodarone 400 mg, po, t.i.d. times one week and then 400 mg, po, q.d. 2. coumadin 2.5 mg, po, q.d. 3. captopril 12.5 mg, po, t.i.d. 4. digoxin 0.125 mg, po, q monday, wednesday, and friday 5. lipitor 5 mg, po, q.d. 6. aspirin 325 mg, po, q.d. [**doctor first name 900**] [**name8 (md) 901**], m.d. [**md number(1) 2144**] dictated by:[**last name (namepattern1) 104014**] medquist36 d: [**2116-3-16**] 16:44 t: [**2116-3-18**] 10:10 job#: [**job number 27571**]",1
138,"admission date: [**2135-11-19**] discharge date: [**2135-11-20**] date of birth: [**2078-11-11**] sex: m service: medicine allergies: penicillins / iodine; iodine containing / carbamazepine attending:[**first name3 (lf) 14037**] chief complaint: shortness of breath major surgical or invasive procedure: hemodialysis history of present illness: 56 yo m with esrd on hd, chf (ef 30%) presenting progressive sob, ""feeling like (i'm) suffocating"". two weeks ago, the patient sustained a mechanical fall ([**2135-10-31**], head ct negative, cxr neg), to his left chest wall and left jaw. the pt has been reporting increasing sob since this fall from his baseline sob, and intermittent left sided chest pain (in location of bruise). per son's report the pt has sob at baseline, not requiring home oxygen, and was recently placed on 2l nc home o2 for dyspnea. per son's report the pt cannot lay flat, and has to sleep propped up in a sitting or standing position. he does not move around much at baseline, and sits in a chair all day, occasionally walking around. per son, the pt has not missed his hd (mwf). patient underwent usual hd yesterday (mwf) which he tolerated well by report. he has continued to take his meds. son also reports increasing lethargy and disorientation, as pt has difficulty sleeping b/c of sensation of sob. in [**last name (lf) **], [**first name3 (lf) **] son's report, no palpitations, abd pain, n/v/d/c. poor po intake. occasionally refuses treatment, and per son, ""difficulty to deal with."" of note, he has an allergy to iv contrast- causing a rash. . in the ed, the pt was satting 94% on 4l nc. noted to be in ""mod respiratory distress,"" using accessory muscles, placed on nrb, satting 99%. went for cta, which was negative for pe and dissection, demonstrating , with the plan being to dialyze immediately after cta given contrast allergy and volume overload. however, apparently pt initially refused hd. pt was then transferred to [**hospital unit name 153**] for further care. in [**name (ni) 153**], pt requested hd. renal consult was called, and stated the renal attending felt the pt could be dialyzed in am. also, pt was with elevated troponins, but flat cks, and ckmb x 2. with lateral st depressions in v3-v6, and ste in leads v1-v3. past medical history: seizures since childhood, which began as generalized tonic-clonic. he was treated with phenobarbitol and mysoline. later, was changed to depakote and dilantin. depakote was discontinued roughly 4 years ago due to elevated ammonia levels. since, then his seizures have increased in frequency and severity. as a result, muliple medications inculding lamictal, trileptal, tegretol and keppra have been tried and he has most recently been on combination of keppra and lamictal. his seizures have been occuring about once every 1-2 months. usual episodes are characterized by confusion and disorientation with rare, generalized tonic clonic episodes. as per omr notes, he has a history of non-convulsive status which presented as confusion in the past and responded to ativan. -esrd on hd, due to idiopathic glomerulonephritis, s/p two failed renal transplants -hypertension -hypothyroidism -peripheral [**name (ni) 1106**] disease -hypoparathyroidism -hepatitis c -chf-diastolic dysfunction (ef>30% in [**4-/2135**]) -svt/avnrt s/p ablation -multiple fistulas -h/o mrsa line infection social history: smoked since he was young, per son, since he was 17-18 y/o. used to smoke heavier, now weaned to [**2-13**] ppd, no alcohol or ivda. has been on disability since [**2115**]. family history: mother with breast ca father alive, with cad, chf sons-healthy physical exam: t 98.0, bp 163/99, p 89, r17 100% ra ill appearing male in nad perrl op clr. mmm 9cm jvp regular s1,s2. no m/r/g b/l basilar crackles, extending to [**2-13**] lung ht. +bs. soft. nt. nd no le edema/cyanosis/clubbing pertinent results: ecg: 90bpm, l axis, nl intervals, non-specific ivcd, twi i/l, std v5-v6, j pt elev in v1/v2, unchanged from previously. . cxr: 1. worsening congestive heart failure. 2. linear atelectasis within right lung base. 3. cardiomegaly. 4. dialysis access catheter in stable position within the mid svc. . ct chest/abd: 1. no pulmonary embolism or aortic dissection. 2. bilateral pleural effusions, cardiomegaly, and pulmonary edema. the previously visualized pulmonary nodules are not visualized today, but could be obscured by the other lung findings. 3. cholelithiasis, and prominent common bile duct. no other evidence of cholecystitis. 4. trace free fluid in the pelvis, without other significant abnormality. [**2135-11-19**] 10:25am type-art temp-36.3 po2-76* pco2-50* ph-7.41 total co2-33* base xs-5 intubated-not intuba [**2135-11-19**] 10:10am glucose-85 urea n-23* creat-5.8*# sodium-139 potassium-5.6* chloride-98 total co2-26 anion gap-21* [**2135-11-19**] 10:10am ck(cpk)-76 [**2135-11-19**] 10:10am ck-mb-notdone ctropnt-0.12* [**2135-11-19**] 10:10am wbc-5.8 rbc-4.34* hgb-12.5* hct-36.2* mcv-84 mch-28.8 mchc-34.5 rdw-18.8* [**2135-11-19**] 10:10am neuts-61 bands-1 lymphs-15* monos-17* eos-0 basos-1 atyps-5* metas-0 myelos-0 [**2135-11-19**] 10:10am plt smr-normal plt count-244 [**2135-11-19**] 10:10am pt-12.6 ptt-28.4 inr(pt)-1.1 head ct: comparison was made with the previous study of [**2135-10-31**]. again, mild brain atrophy and mild changes of small vessel disease are seen in the periventricular white matter. no evidence of hemorrhage, mass effect, or midline shift seen. exuberant [**date range 1106**] calcifications are noted. impression: stable appearance of the brain compared to the previous ct examination of [**2135-10-31**]. no evidence of acute intracranial abnormalities. brief hospital course: 57 yo m w/ esrd on hd, who p/w chf and ongoing cp, w/ non-focal exam, ruled out for pe/dissection, w/ evidence of vol o/l, admitted to [**hospital unit name 153**] for dialysis. . 1) pulm edema- initially assessed as vol o/l vs worsening chf. o2 sat near baseline of prior week, but unclear why patient inceasingly hypoxemic over the prior month (previously not on oxygen). ? possible decompensation in cardiac fxn given that patient has not missed dialysis sessions and was not grossly volume overloaded on exam. ecg w/o significant changes. patient was admitted to [**hospital ward name **] icu, ruled out for mi. continued on bb/acei. had planned to check tte but patient left ama immediately after he was transferred to the floor on hd2.| . 2) contrast allergy- history not c/w anaphylaxis. initial plan in ed had been to premedicate w/ steroids and diphenydramine followed by dialysis. on admission to [**hospital unit name **], renal refused to dialyse sighting lack of clear indication and that patient had add'l room as far as hypoxia to tolerate the osmotic load. patient had no adverse reaction to the conrast dye administration. . 3) cp- likely msk given recent fall. ruled out for dissection/pe. romi'd as above.-pain well controlled w/ percocet. . 4) sz d/o- averaging 1 tonic/clonic per month -stabilized on keppra/lamictal/oxazepam . 5) htn- bp mildly elev on admission but did not receive antihtn on day of admission. -cont acei/bb . 6) esrd- no absolute indication for dialysis. -planned for dialysis on transfer to floor but patient left ama. medications on admission: . acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. lamotrigine 150 mg tablet sig: one (1) tablet po qam (once a day (in the morning)). 3. lamotrigine 100 mg tablet sig: two (2) tablet po qpm (once a day (in the evening)). 4. levetiracetam 250 mg tablet sig: 1.5 tablets po bid (2 times a day). 5. oxazepam 10 mg capsule sig: one (1) capsule po hs (at bedtime). 6. metoprolol succinate 100 mg tablet sustained release 24hr sig: two (2) tablet sustained release 24hr 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). 8. b-complex with vitamin c tablet sig: one (1) tablet po daily (daily). 9. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 10. nifedipine 60 mg tablet sustained release sig: two (2) tablet sustained release po daily (daily). 11. lisinopril 20 mg tablet sig: two (2) tablet po bid (2 times a day). 12. percocet 5-325 mg tablet sig: 1-2 tablets po every six (6) hours as needed for pain. disp:*15 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: . discharge condition: . discharge instructions: patient left ama followup instructions: .",0
139,"admission date: [**2123-6-16**] discharge date: [**2123-6-25**] service: medicine allergies: levaquin attending:[**first name3 (lf) 759**] chief complaint: change in mental status and foul smelling urine major surgical or invasive procedure: incision and drainage of right lower extermity clot left arterial line history of present illness: [**age over 90 **] yo female with mmp who is being treated with lovenox for dvt found in [**3-20**], with hx of frequent utis and urosepsis with resistent klebsiella (most recent positive cx in [**4-17**]), who was in nsoh living with grand-daughter until 2 days ago when she was noticed to have increased somnolence, and stopped taling. she had diarrhea last week and decreased po intake over the past few days. she has stopped talking today which is unusual for her and usually indicates an infection. family does notice she seems to have a tender l leg. she is unable to walk at baseline she has had increased leg edema over the last several days. she has an upcoming appointment in clinic with dr. [**first name (stitle) **] on monday. code status was reviewed and patient is full code at this point. . in the ed, has positive ua. started on meropenem. leni shows residual clot seen adjacent to vessel walls in the l cfv/sfv/[**doctor last name **]. normal waveforms demonstrated. all vessels were patent. past medical history: - dvt [**3-20**] on lovenox - right tkr, wheel-chair bound - htn - s/p cva - left thalamic and cerebellar with residual right-sided hemiparesis. - pmr - h/o asymptomatic r subclavian aneurysm - mild dementia - cataracts - fe deficiency anemia--egd [**8-/2111**] showed gastritis & h pylori. did not want antibiotics. treated with zantac. colonoscopy (-) - chf echo [**6-14**] ef 40% inf wall hypok mod as area 3cm, peak gradient 60, mean 38. 1+ai. pmibi neg [**6-15**] with fixed inf defect - ugib due to pud seen on egd, [**2119**] - s/p pacer for complete heart block by dr. [**last name (stitle) 1911**]. social history: lives with two grandchildren who provide 24 hour care and also has vna.non-ambulatory s/p right tkr, uses wheel-chair. on last admit was recommended for thickened liquid puree diet. physical exam: 98.9 108/92 74 19 100% ra wt 102#, 4'8"" gen: elderly, answers with one word, nad, responds to questions and commands heent: mmd, eomi, pupils constricted, prior surgery, chest: cta anterior cv: s1s2 3/6 sem loudest at lusb (creshendo-decreshendo) abd; hypoactive bs, soft, ntnd ext: lle with 2+ edema, no purulence or fluctuance neuro: responds to questions with one word answers, nods head, follows commands, moves all limbs pertinent results: admission labs: [**2123-6-16**] 7:35p 147 115 18 agap=15 -------------< 92 4.4 21 0.8 93 4.7 \ 11.2 / 232 / 33.7 \ n:64.9 l:29.4 m:3.7 e:1.9 bas:0.2 colorstraw appearclear specgr1.019 ph 5.0 urobilneg bilineg leuktr bldsm nitrpos prottr gluneg ketneg rb0-2 wbc21-50 bactmany yeastnone epi0 chest (pa & lat) [**2123-6-16**] 8:42 pmtechnique and findings: pa and lateral chest x-ray dated [**2123-6-16**] is compared to the pa and lateral chest x-ray of [**2123-3-17**]. there is a new large right pleural effusion. the heart displays stable enlargement. the mediastinal and hilar contours are unremarkable. the lungs show no focal areas of consolidation to suggest pneumonia. there is mild prominence of the perihilar pulmonary vasculature with peribronchial cuffing indicating mild congestive heart failure. left- sided pacemaker is in unchanged position. the aorta is calcified throughout its course. impression: interval development of right-sided pleural effusion. mild congestive heart failure. no focal areas of consolidation to suggest pneumonia. unilat lower ext veins left [**2123-6-16**] 8:03 pm impression: interval partial recanalization of the left common femoral, superficial femoral, and popliteal veins. cardiology report echo study date of [**2123-6-22**] conclusions: the left atrium is elongated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is severely depressed with global hypokinesis and akinesis of the distal anterior wall /antero-septum and apex. 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 severe aortic valve stenosis. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. [due to acoustic shadowing, the severity of mitral regurgitation may be significantly underestimated.] the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. compared with the findings of the prior report (tape unavailable for review) of [**2120-6-28**], the lvef has significantly decreased and the aortic stenosis is now severe. impression: severe aortic stenosis with severely depressed lvef. regional wall motion abnormalities c/w cad (multivessel). [**2123-6-20**] 11:52 am urine site: catheter **final report [**2123-6-21**]** urine culture (final [**2123-6-21**]): no growth. [**2123-6-16**] 7:35 pm urine site: catheter **final report [**2123-6-18**]** urine culture (final [**2123-6-18**]): culture workup discontinued. further incubation showed contamination with mixed fecal flora. clinical significance of isolate(s) uncertain. interpret with caution. gram negative rod #1. >100,000 organisms/ml.. gram negative rod #2. 10,000-100,000 organisms/ml.. brief hospital course: 1) uti: the patient was found to have a positive ua on admission. given her history of esbl resistant klebsiella utis in the past, she was treated with imipenem for 7 days per id (started [**2123-6-16**]). her urine culture showed fecal contamination, but repeat urinalysis and culture was negative after 5 days of treatment with imipenem. 2) chf with severe as / pulmonary edema / pleural effusion - on the second morning of admission, the patient became markedly hypertensive and hypoxic with abg showing respiratory acidosis: 7.15/60/129. she had been given fluid boluses overnight for decreased urine output. she was felt to be fluid overloaded and also hypertensive which led to pulmonary edema and given lasix and nitro paste. she had unchanged ekg and a small troponin leak in the setting of increased demand, cxr showed pulmonary edema with pleural effusion which was felt to be likely chf related. she reponded well to bipap while in [**hospital unit name 153**] and was back to room air for the remainder of admission. she got an echocardiogram which showed ef of 30% and av area of 0.7 cm2, worse than previous echo in [**2120**]. she was converted to long acting toprol. an ace was considered but used with caution given her as. 3) rle swelling: the patient had a swollen bump on her left leg which appeared red, warm and fluctuent. general surgery was called to i&d this area. it revealed old clot with culture and gram stain negative on prelim results. she was treated with morphine for pain in this area after the procedure. three days later, it spontaneously started bleeding and surgery was called to bedside. pressure was applied. the recommendation was to discontinue wet to dry dressings as these can remove the scar tissue and exacerbate bleeding. 4) altered mental status - after beginnig the antibiotic therapy, the patient returned to baseline per granddaughter which was cooperative, responsive, and oriented occasionally only to herself. the night of [**6-22**] pt was less responsive after 1:30 am (got 2 mg morphine at 12:30 am for pain and sob until 8 am. head ct was negative and glucose was normal. this resolved by 9 am so narcotic was most likely cause, and morphine was used sparingly after this. 5) bleeding/anemia: her hct was stable during admission until the am of [**6-21**] when the rn noted bleeding out of l le i&d site and left old a-line site. pressure held and hemostatsis obtained. lmwh was at therapeutic level of 0.7, but her hct down to 23 the next and family refused transcusion less than 25. her lovenox decreased to qd dosing given her risk to bleed, family reluctance to transfusion, and that her repeat u/s showed recaunulazation (despite qd dosing and 0.3 lmwh). she received 1 unit prbc with lasix in the middle and had no shortness of breath or bleeding. she did not rebleed from this area or the left wrist in the last four days of admission and her hct was stable around 30. 6) dvt: treatment was continued for dvt previously noted. her lovenox was changed to [**hospital1 **] dosing as factor x level was subtherapeutic. 7) htn: her lopressor was continued but changed to metoprolol. isordil was added to help with bp control. an ace inhibitor could also be considered but both agents used with caution given her as. 8) hypernatremia - she was noted to be hypernatremic on admission. her imipenem was changed to d5 water and free water intake was encouraged. she was maintained on low salt diet. her sodium improved to normal. 9) pmr - she was continued on prednisone 1 mg. 10) fen: per swallow eval last admit, the patient should be on thickened liquid puree diet, and is at risk for aspiration. family does not want feeding tube and feels this risk is acceptable. aspiration precautions. 11) her code status remained full during admission. this was extensively discussed with granddaughter and hcp [**name (ni) **] [**name (ni) 24052**] [**telephone/fax (1) 108082**] pager [**telephone/fax (1) 108083**]. medications on admission: prednisone 1 mg tablet sig metoprolol tartrate 25 mg [**hospital1 **] acetaminophen albuterol sulfate 0.083 % solution sig: one (1) treatment prn furosemide 40 mg tablet qd pantoprazole sodium 40 mg qd nystatin-triamcinolone 100,000-0.1 unit/g-% cream sig enoxaparin sodium 40 mg/0.4ml qd discharge medications: 1. prednisone 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 3. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 5. enoxaparin sodium 40 mg/0.4ml syringe sig: one (1) injection subcutaneous once a day. disp:*60 injection* refills:*2* 6. isosorbide dinitrate 10 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 7. docusate sodium 150 mg/15 ml liquid sig: one hundred (100) mg po bid (2 times a day). disp:*1 bottle* refills:*4* 8. furosemide 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 9. albuterol sulfate 0.083 % solution sig: one (1) nebulizer inhalation every six (6) hours as needed for shortness of breath or wheezing: and give extra dose of lasix for unresponsive shortness of breath. disp:*30 nebulizers* refills:*2* 10. atrovent 0.02 % solution sig: one (1) nebulizer inhalation every 6-8 hours as needed for shortness of breath or wheezing: and give extra dose of lasix for unresponsive shortness of breath. disp:*30 nebulizers* refills:*2* 11. metoprolol succinate 100 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). 12. adverse reaction no opiates or benzos! discharge disposition: extended care facility: [**hospital3 1186**] - [**location (un) 538**] discharge diagnosis: urinary tract infection pulmonary edema hypertension congestive heart failure bleeding secondary: deep vein thrombosis diagnosed in [**3-20**], on lovenox polymyalgia rheumatica dementia discharge condition: patient was breathing comfortably on room air, was responsive, oriented only to herself. she was at her baseline per family. discharge instructions: you are being discharged to [**first name4 (namepattern1) 1188**] [**last name (namepattern1) **]. please take the medication regimen listed below. if you have fevers, chills, bleeding, shortness of breath or other concerns, please call your doctor or return to the ed. followup instructions: please follow up with dr. [**first name (stitle) **],[**first name3 (lf) **] s. [**telephone/fax (1) 250**] in [**2-14**] weeks after discharge from rehab.",1
140,"admission date: [**2119-5-30**] discharge date: [**2119-7-2**] date of birth: [**2100-12-27**] sex: m service: medicine allergies: penicillin g / ceftriaxone / phenytoin / meropenem attending:[**first name3 (lf) 2291**] chief complaint: seizure major surgical or invasive procedure: [**2119-5-31**]: burr hole and abscess aspiration [**2119-6-21**] left craniotomy drainage of brain abscess [**2119-6-28**] re-do left craniotomy drainage of brain abscess history of present illness: 18 y/o m in good health first presented to osh [**5-27**] following first seizure. pt had generalized seizure, was brought to osh where ct head was in itially interpreted as normal, and patient started on po dilantin. plan for outpatient mri. the patient had no neurologic deficits, constitutional symptoms, or other findings at that time, per report. he returned home, and had progressively worsening headaches over the past 2 days. earlier today, the patient had 2 generalized seizures and was taken again to an osh where ct head with iv contrast demonstrated a 2.5 cm ring enhancing mass in the left temparoparietal lobe. the patient had a temperature of 101.9 at the osh and was administered iv ctx/vanco/flagyl. upon arrival to [**hospital1 18**], the patient is awake and responsive, interviewed in spanish. he describes headaches, but otherwise denies any recent problems. [**name (ni) **] his mother, he usually speaks and undedrstands some english, but has been unable to do so over the past 3 days. past medical history: denies. no history of pediatric infections, recurrent infections. social history: immigrated from [**country 13622**] republic. lives with family. no recent travel. does not use illicit substances, does not inject drugs. family history: non-contributory physical exam: admission: t: 99.4 bp: 130/64 hr:90 r:18 o2sat:100/2l-nc awake and alert cooperative with exam names [**1-10**] objects in spanish makes paraphasic errors and neologisms poor repetition pupils equally round and reactive to light extraocular movements intact bil without abnormal nystagmus facial strength and sensation intact and symmetric hearing intact to voice palatal elevation symmetrical sternocleidomastoid and trapezius normal bilaterally tongue midline without fasciculations normal bulk and tone bilaterally no abnormal movements, tremors strength full power [**5-13**] throughout no pronator drift sensation intact to light touch x 4 ext toes downgoing bilaterally non-dysmetric on finger-nose-finger physical exam upon discharge: afebrile, bp 100s/60s, hr 80s, satting 99%ra general: alert, conversant. skin: peeling skin on arms and legs. no erythema or drainage at picc site. heent: line of staples on left occiput. no erythema or discharge surrounding staples. no facial edema. sclera anicteric, conjunctiva clear. neck: supple, jvp not elevated, no lad lungs: ctab, no wheezes, rales, rhonchi cv: rrr, normal s1 + s2, no m/r/g abdomen: soft, nt, nd, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused (brisk cap refill), 2+ pulses, no clubbing, cyanosis or edema. no lesions on palms or soles. neuro:cn 2-12 intact, sensation throughout, [**5-13**] stregnth throughout. can walk on heels and toes. pertinent results: [**2119-5-30**]: cxr- impression: normal chest. [**2119-5-31**]: mri brain- limited planning study. peripherally t1 hyperintense lesion in the left temporo-parietal lobe with surrounding perilesional edema causing mass effect on the ocipital [**doctor last name 534**] of left lateral ventricle. this has significantly increased in size since the prior ct dated [**2119-5-27**]. the differentials for this includes infection (abscess), inflammatory lesion or tumefactive multiple sclerosis or subacute hematoma. given the short term increase compared to the ct head study of [**2119-5-27**], neoplastic etiology is less likely; however, lymphoma related lesion if the pt. is immunosuppressed cannot be completely excluded. correlate with complete mr imaging an labs. [**5-31**] ct head: immediately status post left parietal burr hole and aspiration of the ring-enhancing lesion with associated vasogenic edema in the left parietal lobe, apparently representing known abscess (according to the given history). there is a small amount of intralesional gas and blood, post-procedure [**6-1**] echo: impression: no valvular vegetations or abscesses appreciated. [**6-1**] panorex: there is no evidence of gross decay or dental infection. his 3rd molars appear to be impacted and may require removal in the future. [**2119-6-16**] head ct impression: interval increase in the size of a left rim-enhancing brain lesion measuring 1.9 x 3.7 x 3.5 cm. [**2119-6-16**] rue u/s impression: no dvt. [**2119-6-17**] ruq u/s impression: normal abdominal ultrasound. no intra- or extra-hepatic bile duct dilation. [**2119-6-18**] mri head w/ contrast conclusion: continued enlargement of the abscess, now with contact with the ventricle and at least subependymal enhancement. [**2119-6-21**] head ct impression: expected post-surgical changes, immediately after left parietal craniotomy for evacuation of an intracranial abscess. pneumocephalus and small intraparenchymal blood at the resection site with surrounding edema are noted. [**2119-6-23**] cxr impression: no acute chest abnormality. [**2119-6-27**] head mri impression: 1. overall evidence of progression with interval thickening of the abscess cavity, extension of adjacent flair signal and new involvement of the left occipital [**doctor last name 534**] subependyma. 2. no new parenchymal abscesses identified. [**2119-6-29**] head ct impression: expected postoperative changes immediately after left parietal craniotomy for evacuation of intracranial abscess with pneumocephalus, vasogenic edema, and small amount of intraparenchymal blood. [**2119-6-12**] peripheral flow cytometry interpretation: non-specific t cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by b-cell lymphoma are not seen in specimen. correlation with clinical findings and morphology is recommended. abscess cultures [**2119-5-31**] 1:05 pm abscess intercranial. **final report [**2119-6-8**]** gram stain (final [**2119-5-31**]): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. 4+ (>10 per 1000x field): gram positive cocci. in pairs and singly. wound culture (final [**2119-6-8**]): streptococcus anginosus (milleri) group. moderate growth. sensitivity testing performed by sensititre. clindamycin mic <= 0.12 mcg/ml. ceftriaxone sensitivity requested by [**first name4 (namepattern1) **] [**last name (namepattern1) 8021**] [**9-/3768**] [**2119-6-6**]. sensitive to ceftriaxone mic = 0.125mcg/ml, sensitivity testing performed by etest. sensitivities: mic expressed in mcg/ml ________________________________________________________ streptococcus anginosus (milleri) group | clindamycin----------- s erythromycin----------<=0.25 s penicillin g----------<=0.06 s vancomycin------------ <=1 s anaerobic culture (final [**2119-6-4**]): no anaerobes isolated. [**2119-6-21**] 2:00 pm swab abscess. **final report [**2119-6-27**]** gram stain (final [**2119-6-21**]): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. wound culture (final [**2119-6-23**]): no growth. anaerobic culture (final [**2119-6-27**]): no growth. [**2119-6-28**] 10:25 pm swab site: brain left brain abscess deep. gram stain (final [**2119-6-29**]): no polymorphonuclear leukocytes seen. no microorganisms seen. wound culture (final [**2119-6-30**]): no growth. anaerobic culture: ___________________________________________ [**2119-6-28**] 10:15 pm swab site: brain left access point. gram stain (final [**2119-6-29**]): no polymorphonuclear leukocytes seen. no microorganisms seen. wound culture (final [**2119-6-30**]): no growth. anaerobic culture: ___________________________________________ [**2119-6-28**] 10:30 pm swab site: brain left brain abscess 2nd focus. gram stain (final [**2119-6-29**]): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. wound culture: ______________________________________________ anaerobic culture: __________________________________________ [**2119-5-31**] 7:35 am blood (toxo) toxoplasma igg antibody (final [**2119-6-2**]): positive for toxoplasma igg antibody by eia. 29 iu/ml. reference range: negative < 4 iu/ml, positive >= 8 iu/ml. toxoplasma igm antibody (final [**2119-6-2**]): negative for toxoplasma igm antibody by eia. interpretation: infection at undetermined time. [**2119-5-31**] 07:20pm blood aspergillus galactomannan antigen-test - neg [**2119-5-31**] 07:42pm urine histoplasma antigen-test [**2119-5-31**] 07:20pm blood cysticercosis antibody-test - neg [**2119-5-31**] 07:20pm blood b-glucan-test - neg [**2119-6-2**] 10:55am blood hiv ab- negative [**2119-6-10**] 05:17am blood cd5-done cd23-done cd45-done hla-dr[**last name (stitle) 7735**] [**name (stitle) 7736**]7-done kappa-done cd2-done cd7-done cd10-done cd19-done cd20-done lambda-done [**2119-6-14**] 06:40am blood strongyloides antibody,igg-pnd microbiology - blood cultures [**2119-6-23**] 9:00 pm blood culture x 2: no growth [**2119-6-22**] 12:39 pm blood culture x 2: no growth [**2119-6-18**] 10:00 am blood culture x 2: no growth [**2119-6-17**] 3:26 am blood culture x 2: no growth [**2119-6-16**] 8:14 pm blood culture x 2: no growth [**2119-6-15**] 9:02 am blood culture x 2: no growth [**2119-6-9**] 8:44 pm blood culture x 2: no growth [**2119-6-8**] 4:48 am blood culture x 2: no growth [**2119-6-4**] 9:36 pm blood culture x 2: no growth [**2119-5-31**] 7:35 am blood culture x 2: no growth [**2119-5-30**] 11:30 pm blood culturex 2: no growth lfts [**2119-5-30**] 11:30pm blood alt-22 ast-26 alkphos-103 totbili-0.3 [**2119-5-31**] 01:43am blood alt-21 ast-27 alkphos-108 totbili-0.3 [**2119-6-5**] 11:29am blood alt-33 ast-25 alkphos-93 amylase-54 totbili-0.1 [**2119-6-8**] 04:48am blood alt-89* ast-90* alkphos-82 totbili-0.1 [**2119-6-9**] 04:57am blood alt-126* ast-123* [**2119-6-10**] 05:17am blood alt-144* ast-122* ld(ldh)-381* [**2119-6-11**] 05:21am blood alt-158* ast-109* [**2119-6-12**] 05:34am blood alt-179* ast-82* [**2119-6-13**] 05:49am blood alt-173* ast-70* alkphos-112 totbili-0.3 [**2119-6-14**] 06:39am blood alt-173* ast-55* alkphos-116 totbili-0.4 [**2119-6-15**] 06:07am blood alt-117* ast-29 alkphos-105 totbili-0.4 [**2119-6-16**] 05:44am blood alt-125* ast-40 [**2119-6-17**] 03:27am blood alt-249* ast-136* ld(ldh)-494* ck(cpk)-36* alkphos-89 totbili-0.3 [**2119-6-19**] 05:53am blood alt-185* ast-30 [**2119-6-20**] 05:00am blood wbc-12.4* rbc-3.99* hgb-11.8* hct-36.0* mcv-90 mch-29.5 mchc-32.7 rdw-13.1 plt ct-317 [**2119-6-21**] 05:47am blood alt-229* ast-72* alkphos-104 [**2119-6-22**] 04:57am blood alt-240* ast-56* alkphos-117 totbili-0.3 [**2119-6-23**] 08:16am blood alt-175* ast-47* alkphos-111 totbili-0.5 [**2119-6-25**] 04:04am blood alt-123* ast-33 alkphos-104 totbili-0.4 [**2119-6-26**] 02:13am blood alt-113* ast-31 alkphos-106 totbili-0.3 [**2119-6-27**] 05:34am blood alt-106* ast-33 alkphos-104 totbili-0.4 urinalysis [**2119-6-24**] 04:40pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.5 leuks-neg [**2119-6-23**] 08:58pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-tr [**2119-6-18**] 06:10am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-neg [**2119-6-16**] 04:34pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-neg [**2119-6-4**] 09:37pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-tr brief hospital course: 18yo m with no pmh admitted for seizures, fever and ams, found to have brain abscess, cultures positive for s. anginosus s/p i&dx3; treatment course complicated by multiple drug allergies, and red man syndrome in setting of vancomycin infusion. # brain abscess: pt initialy given vancomycin/ceftriaxone/flagyl for broad coverage and on [**2119-5-31**], the pt unerwent burr hole and aspiration without complication. pt given dilantin and keppra for seizure prophylaxis initialy. brain abscess grew out strep anginosus. pt had thorough workup to investigate etiology: panorex of teeth, tte, tee and ct a+p. ct a+p showed cecal thickening and typhlitis, possibly the original source of infection, although pt denied every having gi symptoms. after patient's initial post-op course, he developed daily fevers up to 103 ultimately attributed to antibiotic drug reaction. see below for antibiotic course. after a trial of several antibiotics, it was felt that he had a beta-lactam allergy and he was ultimately switched to vancomycin and flagyl which he ultimately tolerated well. pt had repeat head imaging (head ct [**6-16**], head mri [**2119-6-18**]) which demonstrated enlargement of the abscess. the patient was then taken for a second i&d ([**2119-6-21**]), via mini craniotomy. the patient tolerated this procedure well, and returned to the medicine floor that day. post-operative neurologic exam was within normal limits. of note, abscess cultures were negative (including fungi and anaerobes). repeat imaging on [**6-27**] with mri suggested possible extension of the abscess again. the patient underwent third i&d on [**2119-6-28**]. no pus or abscess was found during this procedure (washings were negative) and his prior mri findings were likely attributed to post-op changes rather then progressing abscess infection. pt remained neurologically intact. #surgical interventions for abscess the pt underwent mutiple i&ds for s. anginosus brain abscess: [**2119-5-31**], [**2119-6-21**], [**2119-6-28**]. pt is due to get staples removed early [**2119-7-9**] (10 days since most recent i+d). # pharmacologic treatment of abscess/red man syndrome/b-lactam allergy: the pt was treated with numerous antimicrobial agents. treatment course was complicated by drug-induced rashes and fevers. pt was placed on empiric antibiotic therapy with vanc/ceftriaxone/flagyl until speciation was determined. pt was then switched to penicillin g. due to rash, penicillin was discontinued and he was then switched to ceftriaxone/flagyl. patient's rash worsened and he had daily high fevers 103, and he was then switched to meropenem. rash temporarily abated, but returned worse than before (morbilliform from head to toe, also with fevers). meropenem was discontinued and pt was placed on vancomycin/flagyl. during his initial vancomycin infusion ([**2119-6-16**]), pt developed characteristic 'red man syndrome' with cehst pain, pruritis, redness, agitation during the infusion. the patient was transferred to the micu for further observation and his vancomycin infusion rate was slowed down. he was initialy given solumedrol during his vanco infusions and that was then stopped as his clinical picture and rash improved. he was maintained on vancomycin (slow infusion over 3 hrs) and flagyl for the remainder of his hospital course and tolerated this well. the patient was discharged on vancomycin and flagyl, four week course from the date of third i&d ([**7-1**]- [**2119-7-26**]). pt will continued to get weekly cbc with diff, bun, cr, vanco trough, and close follow up with id and neurosurgery. # vancomycin infusion reaction: during patient's vancomycin infusion ([**2119-6-16**]), the patient became acutely agitated, tachypneic, and complained of worsened pruritus and sudden-onset chest pain with redness throughout body. the patient was diagnosed with ""red man syndrome."" the patient was transferred to the micu for supervision of further infusions. infusion rate was slowed (over 3hours). he was initialy ""pre-treated"" with diphenhydramine and methylprednisolone prior to vanco infusion, to further reduce rash and pruritus. methylprednisolone was eventually discontinued and patient tolerated vancomycin slow infusions without difficulty. # transaminitis: the patient had intermittently elevated lfts. transaminitis was likely due to drug reaction (phenytoin vs beta-lactams). ruq u/s and abdominal ct demonstrated no abnormalities, and bilirubins were normal. lfts trended down and stabalized while on vancomycin and flagyl. # eosinophilia: the patient had a eosinophilia, coincident with rash and transaminitis. eosinophilia was attributed to drug allergy. work up was negative for helminth infection, etc. # seizure prophylaxis: the pt had an apparent seizure after his first i&d. he was placed on phenytoin and levacetiram for seizure prophylaxis. due to concerns that phenytoin was contributing to his rash, fevers, and transaminitis, phenytoin was discontinued later in the hospital course. the patient was maintained on levacetiram throughout. he will follow up with neurosurgery to determine when he can stop this medication. # general infectious work-up: the patient underwent a thorough infectious work-up, including panorex xray, dental consult, tte, tee with bubble study, abdct, serial blood cultures, and assays. abdominal ct with contrast was notable for typhlitis and prominent mesenteric, periaortic, inguinal and femoral lymph nodes. testicular exam was normal. flow cytometry was negative for a lymphoma/leukemia. true etiology of his strep anginosus brain abscess was unclear. [**name2 (ni) **] ct a+p showed typhlitis, pt denied every having abdominal symptoms. transitional issues: -needs staples removed [**2119-7-9**] -will require 4 weeks of antibiotics as of [**7-1**]- [**2119-7-26**]. pt will get weekly opat labs sent to [**hospital **] clinic. -currently on keppra 750mg [**hospital1 **] for seizure prophylaxis. -has allergy to b-lactams: morbilliform rash, lfts, fevers medications on admission: none discharge medications: 1. acetaminophen 650 mg po q6h:prn pain, headache or t > 38.3 do not exceed 4g/day 2. levetiracetam 750 mg po bid rx *levetiracetam 750 mg 1 tablet(s) by mouth twice a day disp #*60 tablet refills:*2 3. vancomycin 1250 mg iv q 8h infuse over 3 hours 4. metronidazole (flagyl) 500 mg po q8h rx *flagyl 500 mg 1 tablet(s) by mouth three times a day disp #*30 tablet refills:*4 rx *metronidazole 500 mg 1 tablet(s) by mouth q 8 hrs disp #*90 tablet refills:*1 5. sarna lotion 1 appl tp [**hospital1 **] rx *sarna anti-itch 0.5 %-0.5 % apply liberally to areas of rash and peeling skin twice a day disp #*600 milliliter refills:*1 6. heparin flush picc line maintenance and heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent. flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 7. outpatient lab work check once a week: cbc with diff, bun, cr, vanco-trough. fax to dr. [**first name4 (namepattern1) **] [**last name (namepattern1) **] [**telephone/fax (1) 17715**]. 8. vancomycin vancomycin 1250 mg iv q 8h. infuse over 3 hours. disp: 4 week's supply. premedicate with benadryl 25mg po. 9. diphenhydramine 50 mg po q8h give prior to vancomycin dose hold for sedation rr < 12 discharge disposition: home with service facility: [**last name (lf) 486**], [**first name3 (lf) 487**] discharge diagnosis: intracranial abscess hyperexia tonic clonic seizures beta lactam allergy ""red man syndrome"" discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. [**known lastname 111991**], thank you for the privilege of participating in your care. you were admitted to the [**hospital1 69**] because you were found to have an infection in your brain (an ""abscess""). we still do not know where this infection came from. we do not know why you developed this infection in your brain. we performed a very thorough workup to investigate where this infection might have come from. a ct scan of your abdomen showed a possible inflammation or infection which might have been the original source of infection. the imaging of the teeth, chest, heart, rest of your body is all reassuring. the brain abscess required treatment with surgery and antibiotics. after your first surgery, imaging showed that the infection could be getting bigger. for this reason, you had to have two more surgeries. the most recent surgery was reassuring that the infection appears to be gone at this time. laboratory cultures from the first surgery showed infection with bacteria. cultures from the second and third operation did not grow any bacteria, indicating that the antibiotics were treating the infection well. also, the neurosurgeons did not see any infection during the third surgery. this is strong evidence that the infection is disappearing. during your hospitalization, you had a very itchy rash, and many high fevers. the rash and fevers were most likely caused by the antibiotics you took after your first surgery. these antibiotics that you seem to have an adverse reaction to are: penicillin, ceftriaxone and meropenem. you are currently on vancomycin and flagyl antibiotics that are fighting the infection. you are tolerating these medications well. you will need to continue the vancomycin and flagyl for a total 4 week course since your last surgery. thus, you should take it through [**7-26**]. the infectious disease doctors [**name5 (ptitle) **] [**name5 (ptitle) 111992**] [**name5 (ptitle) **] when to stop these medications. when you leave the hospital, it is very important that you continue to take all antibiotics as prescribed. if you do not take all your medicines, it is possible that the infection could come back. a nurse will come to your home to help you with the medications. it is also important to take the medication keppra, 1 pill twice a day. this medication will prevent seizures. you should continue this medication until the neurosurgeons tell you that you can stop. it will likely be for several months. please schedule an appointment with your primary care doctor, dr. [**last name (stitle) **]. also, please go to the appointments scheduled with the neurosurgery and infectious disease teams. it is very important that you go to these appointments. your doctors [**name5 (ptitle) 9004**] to be sure that you continue to recover well. you will also have more imaging of your head, to be sure that the infection is getting smaller. here are some instructions from the neurosurgery team: - your sutures should stay clean and dry until they are removed. - do not wash your head where the wound is until [**7-8**]. (10 days after surgery) at that point you can then wash your hair. ?????? have a friend or family member check the wound for signs of infection such as redness or drainage daily. ?????? exercise should be limited to walking; no lifting >10lbs, straining, or excessive bending. ?????? do not take any anti-inflammatory medicines such as motrin, aspirin, advil, or ibuprofen etc. until follow up. ?????? do not drive until your follow up appointment. followup instructions: follow-up appointment instructions ??????please call ([**telephone/fax (1) 4676**] to schedule an appointment with one of the physician assistant in [**7-18**] days from the time of surgery for staple removal ([**7-9**] you will be due to have the sutures removed). ??????you will need a ct of the brain with contrast in the future. you have an appointment scheduled on [**7-19**] per the neurosurgeons. [**telephone/fax (1) 1669**] is the office phone number for the neurosurgeons. please see appointment time and date below. ?????? you need to follow up with infectious disease on [**7-5**] with dr [**first name8 (namepattern2) **] [**last name (namepattern1) 724**] and dr. [**first name4 (namepattern1) 636**] [**last name (namepattern1) **]. you need the following labs sent weekly to them: cbc with diff, bun, cr, vanco trough, fax to: dr [**first name4 (namepattern1) 636**] [**last name (namepattern1) **] [**telephone/fax (1) 1419**]. the visiting nurses will be notified to do this for you. department: infectious disease when: wednesday [**2119-7-5**] at 11:30 am with: [**first name4 (namepattern1) **] [**last name (namepattern1) 8021**], md [**telephone/fax (1) 457**] building: lm [**hospital ward name **] bldg ([**last name (namepattern1) **]) [**hospital 1422**] campus: west best parking: [**hospital ward name **] garage department: radiology when: wednesday [**2119-7-19**] at 9:15 am with: cat scan [**telephone/fax (1) 590**] building: cc [**location (un) 591**] [**location (un) **] campus: west best parking: [**street address(1) 592**] garage department: neurosurgery when: wednesday [**2119-7-19**] at 10:45 am with: [**name6 (md) **] [**name8 (md) **], md [**telephone/fax (1) 1669**] building: lm [**hospital unit name **] [**location (un) **] campus: west best parking: [**hospital ward name **] garage [**2119-7-21**], 8:30am infectious disease office [**hospital **] medical building, [**last name (namepattern1) 439**], basement [**telephone/fax (1) 457**] [**2119-8-17**] 8:00am with dr [**last name (stitle) 1206**]. neurologist. [**hospital ward name 23**] building clinical center, [**location (un) **].",1
141,"admission date: [**2134-5-31**] discharge date: [**2134-6-4**] date of birth: [**2084-1-1**] sex: f service: medicine allergies: iodine dye / penicillin v / isovue-128 / salicylate attending:[**first name3 (lf) 4891**] chief complaint: hypotension major surgical or invasive procedure: none history of present illness: this is a 50 year old lady with t2dm, hypothyroidism who presented with fever, fatigue, diffuse myalgias and left back pain in the setting of known ecoli uti. in brief her sx reportably began several weeks ago with myalgias, chills and fevers up to 103f. with supportive measures she did not improved and soon developed dysuria. a urine culture from [**5-27**] at her pcps office grew > 100,000 e. coli which was pansensitive. she was started on cipro and when her sx did not improved was admitted to [**hospital1 18**] ed on [**5-29**] where cipro was changed to cefpodoxime because of concern that her uti was not adequately treated with cipro and she was discharged back home. she re-presented yesterday to the ed with persistent symptoms with initial vitals of 98.2 83 105/45 18 100%. she received morphine for pain as well as zofran for nausea. labs were notable for absence of leukocytosis and mildly elevated lactate to 2.3. a renal ultrasound revealed no evidence of abscess. overnight her blood pressures continued to trend down to the 70s and were minimally responsive to 3l of ns with systolics maintained in the 80s. she was noted to have a fever of 101.8 at 10pm. a repeat lactate was 1.2 at 3am. her antibiotics were changed from cefpodoxime to ceftriaxone q24 hrs. her pm trazadone was held. a chest xray demonstrated no acute cardiopulmonary process. a cbc with diff, cortisol and chem 7 were drawn in the morning. a cdiff was sent when the patient endorsed 6 episodes of diarrhea in the last 36 hours. a second iv was placed in addition to a foley catheter. the patient was ultimately transferred to the micu for persistent hypotension despite fluid rescussitation and marked nursing concern. two triggers were called for hypotension overnight. . on arrival to the icu, intial vitals were: 98.0 100/58 90% ra rr 27. she was comfortable, still tired complaining of fatigue. she also endorsed headache, which has been present since her symptoms began. she also reported some left calf pain. . review of systems: (+) per hpi (-) denies cough, shortness of breath, or wheezing. denies chest pain, palpitations, or weakness. denies vomiting, 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: history hysterectomy including cervix anxiety states, unspec irritable bowel syndrome pain syndrome - chronic obesity unspec dm - type 2 diabetes mellitus fatty liver ganglion - joint hypothyroidism vertigo headache social history: works in the [**location (un) 86**] public school system as a teaching aid for students with autism. she is married with 4 kids at home. she is sexually active and monogamous with her husband. -tobacco: denies -etoh: none -drugs: none family history: father diabetes - type ii sister [**name (ni) 3730**]; diabetes; fibromyalgia, hypertension; irritable bowel syndrome; psych - depression; cirrohsis; cva physical exam: admission exam: vs - temp 99.7f bp 116/69 hr 89 rr 20 spo2 100/ra fs=122 general - well-appearing woman in nad, comfortable, appropriate heent - nc/at, eomi, erythema and swelling of tonsils, l>r, no exudates visualized neck - supple, mild swelling but no discrete lymphadenopathy lungs - cta bilat, no r/rh/wh heart - pmi non-displaced, rrr, no mrg, nl s1-s2 abdomen - nabs, soft/nt/obese. palpable spleen tip on exam back - minimal cva tenderness (similar pain with palpation of her thigh muscles) extremities - wwp, no c/c/e, 2+ peripheral pulses (radials, dps) skin - no rashes or lesions neuro - awake, a&ox3, cns ii-xii grossly intact, no focal defecits discharge exam - unchanged from above, except as below: abdomen - +bs, soft, nd, mild ttp in ruq and luq, palpable spleen tip pertinent results: admission labs: [**2134-5-31**] 01:30pm blood wbc-6.6 rbc-4.09* hgb-12.0 hct-36.8 mcv-90 mch-29.3 mchc-32.6 rdw-14.1 plt ct-264 [**2134-5-31**] 01:30pm blood neuts-44* bands-3 lymphs-35 monos-4 eos-4 baso-1 atyps-8* metas-1* myelos-0 [**2134-5-31**] 01:30pm blood glucose-102* urean-12 creat-0.7 na-142 k-3.4 cl-105 hco3-26 angap-14 [**2134-6-1**] 05:40am blood calcium-7.9* phos-3.6 mg-1.8 [**2134-5-31**] 01:46pm blood lactate-2.3* [**2134-6-2**] 05:04am blood lipase-20 [**2134-6-1**] 05:40am blood alt-51* ast-46* ld(ldh)-327* alkphos-84 totbili-0.3 [**2134-6-1**] 05:40am blood cortsol-17.3 [**2134-5-31**] 01:45pm urine color-yellow appear-hazy sp [**last name (un) **]-1.020 [**2134-5-31**] 01:45pm urine blood-neg nitrite-neg protein-30 glucose-neg ketone-tr bilirub-neg urobiln-neg ph-6.0 leuks-neg [**2134-5-31**] 01:45pm urine rbc-2 wbc-4 bacteri-few yeast-none epi-1 discharge labs: [**2134-6-4**] 05:30am blood wbc-7.0 rbc-3.19* hgb-9.5* hct-29.1* mcv-91 mch-30.0 mchc-32.8 rdw-14.8 plt ct-271 [**2134-6-4**] 05:30am blood glucose-119* urean-7 creat-0.6 na-138 k-3.4 cl-107 hco3-25 angap-9 [**2134-6-4**] 05:30am blood albumin-2.9* calcium-7.6* phos-2.5* mg-1.7 micro: -bcx ([**2134-5-31**], [**2134-6-1**], [**2134-6-3**]): ngtd -ucx ([**2134-5-31**]): no growth - final -monospot ([**2134-5-31**]): negative -c. diff ([**2134-6-1**]): **final report [**2134-6-2**]** c. difficile dna amplification assay (final [**2134-6-2**]): negative for toxigenic c. difficile by the illumigene dna amplification assay. (reference range-negative). -cmv ([**2134-5-31**]): **final report [**2134-6-1**]** cmv igg antibody (final [**2134-6-1**]): negative for cmv igg antibody by eia. <4 au/ml. reference range: negative < 4 au/ml, positive >= 6 au/ml. cmv igm antibody (final [**2134-6-1**]): positive for cmv igm antibody by eia. interpretation: suggestive of primary infection. igm antibody may persist for 6 months or longer after primary infection and may reappear during reactivation. greatly elevated serum protein with igg levels >[**2121**] mg/dl may cause interference with cmv igm results. submit follow-up serum in [**1-29**] weeks. -ebv ([**2134-5-31**]): **final report [**2134-6-3**]** [**doctor last name **]-[**doctor last name **] virus vca-igg ab (final [**2134-6-3**]): positive by eia. [**doctor last name **]-[**doctor last name **] virus ebna igg ab (final [**2134-6-3**]): positive by eia. [**doctor last name **]-[**doctor last name **] virus vca-igm ab (final [**2134-6-3**]): negative <1:10 by ifa. interpretation: results indicative of past ebv infection. in most populations, 90% of adults have been infected at sometime with ebv and will have measurable vca igg and ebna antibodies. antibodies to ebna develop 6-8 weeks after primary infection and remain present for life. presence of vca igm antibodies indicates recent primary infection. imaging: -renal us ([**2134-5-31**]): the right kidney measures 10.7 cm and the left 11 cm. there is no evidence of masses, hydronephrosis, abscess, or stones. the visualized bladder is unremarkable. the spleen is enlarged measuring 14.6 cm. impression: no evidence of renal abscess. splenomegaly. -ct abd/pelvis w/o contrast ([**2134-6-1**]): 1. cholelithiasis or biliary sludge within the gallbladder. further evaluation for cholecystitis is limited without intravenous contrast. if clinical concern for cholecystitis exists, a followup right upper quadrant ultrasound could be considered. 2. right adnexal hypodense lesion incompletely characterized on unenhanced ct. 3. hepatic steatosis. 4. enlarged spleen. -cxr ([**2134-6-1**]): lung volumes are low. borderline size of the cardiac silhouette. the presence of minimal fluid overload cannot be excluded. however, there is no overt pulmonary edema. no pleural effusions. -ruq us ([**2134-6-2**]): 1. normal examination of the gallbladder. no evidence for stones or sludge. no evidence for cholecystitis. 2. increased echogenicity of the liver consistent with fatty infiltration. please note that other forms of liver disease including significant fibrosis/cirrhosis cannot be excluded on the basis of this study. 3. splenomegaly of 15 cm. -pelvis us ([**2134-6-2**]): 1. two hemorrhagic cysts on the right ovary. 2. status post hysterectomy. brief hospital course: 50 year old woman with a history of t2dm and hypothyroidism admitted with fever, fatigue and myalgias, course complicated by hypotension, found to have acute cmv infection. # acute cytomegalovirus infection: her initial presentation with a fever, fatigue, diarrhea and diffuse myalgias was initially thought to be consistent with mononucleosis or a similar viral illness. supporting this was 8% atypical cells on her admission cbc/diff and splenomegaly to 15cm on imaging. at admission, monospot was negative and cmv igm was positive with a negative igg which is consistent with acute cmv infection. ebv igg was positive with negative igm suggesting prior exposure. she was treated conservatively with iv fluids and tylenol/nsaids for pain control and fevers. a renal us and ct abd/pelvis (without contrast because of prior adverse reaction to iv contrast) did not show any evidence of renal or preinephric abscess or other causes to explain her fevers. she had a ruq us because of concern for stones/sludge in the gallbladder on her ct abdomen. this us was unremarkable and did not show cholecyctitis or cbd dilation. she also had a pelvic us which was unremarkable aside from two ovarian cysts. she continued to have fevers up to 101.9f during this admission. at discharge, she was off iv fluids and taking adequate po. she has been instructed that cmv infection can take weeks to resolve and that she will likely continue to have these symptoms along with fevers during this time. we considered sending a hiv test, but this was deferred to her pcp given that her cmv infection is a better explaiantion for her symptoms and she has no high risk behaviors for hiv infection. this was communicated to her pcp by email prior to discharge. #hypotension: in the setting of high fevers and poor po intake, she was briefly hypotensive to the high 70 to low 80s systolic on her first night of admission. she was transferred to the micu for closer monitoring where she received iv fluids and did not require pressors. at discharge, she was taking good po and not requiring iv fluids with systolic bp in the 90-120s. #hypoxia: o2 sats briefly in the 88-92% range on room air while in the micu. she was asymptomatic and cxr was unremarkable. likely cause was atelectasis and she was given an incentive spirometer on the floor. she was quickly weaned to room air after transfer to the floor. #transaminitis: lfts mildly elevated this admission to the 40-50s, which is consistent with her acute cmv infection. ruq us was unremarkable with no cholecystitis, stones or cbd dilation. should have repeat lfts 4-6 weeks after discharge to ensure resolution. #uti: she had pansensitive e. coli at an outpatient visit prior to admission, no perinephric abscess or hydro on renal us or on ct abd/pelvis. prior to admission, she was on cipro which was subsequently changed to cefpodox and was continued on ctx for 3 days this admission. she had no urinary symptoms and urine culture was negative at admission. --inactive issues-- #t2dm: appears well controlled, last a1c in atrius records was 6.9% in [**2-/2134**] and has been <7 for the past 2 years. she was not on medications for her diabetes at admission and blood sugar remained well controlled. #hypothyroidism: continued on home dose of levothyroxine 100mcg daily #code status this admission: full (confirmed) #transitional issues: -should have an hiv test as an outpatient given her recent acute cmv infection -will need repeat lfts in [**4-2**] weeks to assess for resolution of her transaminitis -has been instructed to continue to consume plenty of fluids (including juice and sport drinks) while she is having diarrhea and high fevers. -has been advised that she may continue to have fatigue, myalgias and high fevers for a few weeks while her cmv infection resolves medications on admission: medications: (home) -ciprofloxacin 500 mg oral q12h for 7 days (d1=[**2134-5-27**], stopped [**2134-5-29**]) -cefpodoxime 100mg [**hospital1 **] (started [**2134-5-29**], still taking) -sertraline 50 mg oral daily -gabapentin 300 mg oral capsule 1 capsule nightly -ibuprofen 200 mg oral tablet 3 tablets with food twice a day as needed for pain -pravastatin 20 mg oral tablet take 1 tablet every evening for cholesterol -levothyroxine 100 mcg oral tablet take 1 tablet by mouth a day -melatonin oral 1 to 3 mg daily -ginseng oral take daily - available over the counter -blood sugar diagnostic test strips (one touch ultra test strips) invt strp use as directed twice daily -lancets (one touch ultrasoft lancets) misc misc use as directed to test blood sugar twice daily -cinnamon oral pt reports she takes 1 capsule every pm -multivitamin capsule po (multivitamins) 1 po qd -calcium carbonate tablet 650mg po as . medications: (transfer) 1. heparin 5000 unit sc tid 2. insulin sc 3. levothyroxine sodium 100 mcg po/ng daily 4. acetaminophen 325-650 mg po/ng q4h:prn pain 5. multivitamins 1 tab po/ng daily 6. calcium carbonate 500 mg po/ng daily 7. ondansetron 4 mg iv q8h:prn nausea 8. cefpodoxime proxetil 200 mg po/ng q12h 9. pravastatin 20 mg po daily 9. ceftriaxone 1 gm iv once 11. docusate sodium 100 mg po/ng [**hospital1 **] 12. sertraline 50 mg po/ng daily 13. senna 1 tab po/ng [**hospital1 **]:prn constipation 12. gabapentin 300 mg po/ng hs discharge medications: 1. sertraline 50 mg tablet sig: one (1) tablet po daily (daily). 2. gabapentin 300 mg capsule sig: one (1) capsule po hs (at bedtime). 3. ibuprofen 200 mg tablet sig: three (3) tablet po every eight (8) hours as needed for pain for 2 weeks. 4. pravastatin 20 mg tablet sig: one (1) tablet po daily (daily). 5. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 6. melatonin 1 mg tablet sig: 1-2 tablets po at bedtime as needed for insomnia. 7. ginseng oral 8. cinnamon oral 9. multivitamin tablet sig: one (1) tablet po daily (daily). 10. calcium carbonate 650 mg calcium (1,625 mg) tablet sig: one (1) tablet po once a day. 11. acetaminophen 325 mg tablet sig: 1-2 tablets po every four (4) hours as needed for fever or pain. discharge disposition: home discharge diagnosis: primary diagnoses: acute cytomegalovirus infection secondary diagnoses: type 2 diabetes hypertension discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. [**known lastname 112064**], it was a pleasure taking care of you during your admission to [**hospital1 18**] for fever and muscle aches. you were found to have a viral infection called cmv (cytomegalovirus). this will likely take a few weeks to resolve and is thought to be the cause of your weakness, fevers, fatigue and muscle aches. you can be expected to continue to have fevers for at least a couple of weeks while this infection resolves. your blood pressure was low and you were transferred to the icu briefly where you received iv fluids. you blood pressure improved prior to discharge. the following changes were made to your medications: start tylenol (acetaminophen) 325-650mg every 6 hours as needed for pain or fever start ibuprofen 600mg every 8 hours as needed for fever or muscle aches followup instructions: name: [**last name (lf) 54468**],[**first name3 (lf) 54469**] b. location: [**hospital1 641**] address: [**location (un) **], [**location (un) **],[**numeric identifier 2260**] phone: [**telephone/fax (1) 3530**] appointment: monday [**2134-6-7**] 10:50am",1
142,"admission date: [**2126-12-20**] discharge date: [**2126-12-25**] date of birth: [**2073-1-25**] sex: m service: medicine allergies: codeine / compazine / penicillins / metformin / heparin agents attending:[**first name3 (lf) 2763**] chief complaint: fever, altered mental status major surgical or invasive procedure: right foot incision & drainage by podiatry on [**2126-12-20**]. history of present illness: 53m h/o severe copd, tracheomalacia, recent pea arrest in the setting of tracheostomy change, with course c/b vap and c. diff colitis, who is sent to [**hospital1 18**] from [**hospital 100**] rehab in the setting of ongoing fever, and altered mental status. . per [**hospital 100**] rehab transfer summary, he was discharged from [**hospital1 18**] [**2126-11-13**] after being admitted with broken external fixation. he was taken to the or by orthopedics for repair. in that setting, tmax 102 (rectal). he was continued on vanco/flagyl for presumed c. diff, but cultures returned negative, so this was stopped. he was discharged with instructions to complete a course of meropenem until [**11-23**] for esbl e. coli uti based on cultures from [**hospital 100**] rehab. . since returning to rehab, his wbc was increasing, to 19 by report. at some point, he was restarted empirically on antibiotics (linezolid, and imipenem) for unclear source, which were d/c'd on [**12-16**] when his fevers improved. on [**12-19**] he was noted to have a tmax 101.0 at 3pm, and was restarted on linezolid/imipenem empirically. ucx and cxr at nh were unremarkable. he was treated for increasing agitation with zyprexa, increased to 7.5mg tid on [**12-19**]. he was reported to be c. diff positive (no culture data available), and continued on po vancomycin 250mg po tid. . in ed, vs=96.9 112/68 98 14 100% on unclear settings, but cpap by report. tmax 97.9. labs notable for leukocytosis to 13. r foot erythema and fluctuance noted, he recieved iv vanco x 1, and podiatry consulted. i&d performed, which was largely hematoma by report. ua essentially negative. blood and wound cultures sent. he is admitted for further workup of fever, altered mental status. . review of systems: pt on mmv, unable to provide. past medical history: copd with trach on o2 and chronic prednisone, tracheomalacia, h/o tracheal stenosis -type ii dm -diastolic chf -mild pulmonary htn -osteoporosis s/p mid-thoracic vertebral body fracture, hip fx, and r wrist fracture -chronic lbp - pt reports compression fractures from osteoporosis -h/o c. diff colitis -hepatitis b -iron def. anemia -h/o gastric and duodenal ulcers -h/o nephrolithiasis -h/o mrsa nasal swab, mrsa sputum cx social history: mr. [**name13 (stitle) 14302**] was at [**hospital1 100**] rewhab. he quit drinking more than seven years ago. he quit smoking approximately 2+ yrs ago, and has a 60 pack year history. he quit using heroin about eight years ago, after a 20 yr hx. family history: non-contributory. physical exam: admission physical exam: vitals: 96.0 110/71 30 100% on mmv 14/5 vt 450 14 40%. general: no response to voice, but arouses quickly to sternal rub, denies pain (shakes head). heent: mmm neck: supple, jvp not elevated, no lad lungs: clear to auscultation anteriorly, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly neuro: moves all four extremities spontaneously, pupils symmetric. withdraws upper extremities to pain. ext: warm, well perfused, 2+ pulses, no edema. mild erythema bilateral ankles, r le foot wrapped, c/d/i. pertinent results: admission labs: wbc-13.0* rbc-3.46* hgb-9.0* hct-29.0* mcv-84 mch-26.1* mchc-31.1 rdw-17.9* plt ct-520* neuts-77.9* lymphs-14.4* monos-5.9 eos-1.5 baso-0.2 pt-11.9 ptt-26.5 inr(pt)-1.0 glucose-93 urean-18 creat-0.6 na-142 k-4.0 cl-100 hco3-34* angap-12 alt-27 ast-35 ld(ldh)-442* ck(cpk)-94 alkphos-72 totbili-0.4 calcium-9.2 phos-4.3 mg-2.1 crp-22.8* discharge labs: [**2126-12-25**] 05:40am blood wbc-9.5 rbc-4.10* hgb-11.2* hct-33.9* mcv-83 mch-27.2 mchc-32.9 rdw-17.6* plt ct-421 [**2126-12-25**] 05:40am blood pt-12.8 ptt-26.7 inr(pt)-1.1 [**2126-12-25**] 05:40am blood glucose-90 urean-8 creat-0.5 na-141 k-3.4 cl-100 hco3-35* angap-9 [**2126-12-25**] 05:40am blood alt-24 ast-28 ld(ldh)-359* alkphos-63 totbili-0.4 [**2126-12-25**] 05:40am blood calcium-9.1 phos-4.4 mg-1.8 microbiology: [**2126-12-20**] and [**2126-12-21**] bcx: ngtd [**2126-12-21**] sputum gs/culture: negative [**2126-12-21**] ucx: negative [**2126-12-23**] stool c diff: negative [**2126-12-24**] stool c diff: negative radiology: [**2126-12-20**] cxr: ?bilateral pleural effusions, not grosely changed from prior (will need to f/u formal read) [**2126-12-20**] right foot x-ray: no radiographic evidence of osteomyelitis [**2126-12-21**] head ct: impressions: 1. no intracranial hemorrhage. 2. increased soft tissue density material within the left, dominant sphenoid air cell, with other paranasal sinuses relatively well aerated. [**2126-12-21**] non-contrast ct abd/pelvis: impression: 1. there is no evidence of retroperitoneal bleeding. 2. bilateral subpleural atelectases in the right lower lobe and left lower lobe. 3. two kidney stones in the left kidney without evidence of obstruction. 4. new compression fracture of t12. ekg: [**2126-12-20**] 19:00: sinus tach, 102 bpm, na, no ste/std. brief hospital course: mr. [**name13 (stitle) 14302**] is a 53 yo man admitted from rehab with fevers, altered mental status and right foot erythema. right foot cellulitis: x-ray of the right foot was negative for osteomyeltitis. he was started on iv vancomycin for cellulitis for a fourteen day course. podiatry was consulted, and reported patient had a r foot hematoma without evidence of infection s/p i&d [**12-20**], no evidence of osteo on xr. anxiety/depression: mr. [**name13 (stitle) 14302**] was referred to [**hospital1 18**] [**2-11**] fevers and increased agitation over past week prior to admission in the setting of not sleeping. he was noted to be highly anxious while in the hospital, and there was also felt to be an element of depression on his home olanzapine and klonopin. after discussion with his sister, he was started on citalopram 20 mg qd for depression, to be increased as tolerated. on admission he was agitated, though this improved with treatment of his cellulitis. chronic lower back pain: mr. [**name13 (stitle) 14302**] suffers from lower back pain. he was started on standing tylenol, lidocaine patch and prn tarmadol for his symptoms. copd, chronic steroids, s/p trach: patient is s/p trach and was maintained on mmv vent settings of . patient was initially started on stress dose steroids, which was changed back to his home prednisone dose of 7 mg on [**2126-12-24**]. this should be weaned as tolerated per out-patient pcp & pulmonologist. he was continued on bactrim prophylaxis, as well as his home regimen of prednisone, and inhalers. hypotension the patient had a brief episode of hypotension which self-resolved without the use of pressors. decrease hematocrit: patient had a hematocrit drop from 24 to 17, repeated at 19, and was transfused 2 units prbc with increase of hematocrit to 31. though it was suspected the hct of 17 and 19 were false lows, given the significant increase in hct with transfusion, ct abd was ordered to evaluate for any site of occult bleeding and was negative. hemolysis labs (ldh, direct and indirect bilirubin) did not suggest hemolysis. concern for possible c diff colitis: with his history of c diff, vancomycin po was started empirically for c diff pn admission. he had one stool c diff toxin that was negative on [**2126-12-23**] and another that was negative on [**2126-12-24**]. po vancomycin was discontinued. right ulnar/humerus fracture: pain control was continued per home regimen (tylenol, fentanyl patch, klonopin), and patient was continued on home calcium, vitamin d. seizure: patient was continued on home keppra note: per sister, patient has adverse reaction to haldol with twitching and agitation. medications on admission: per last discharge summary: 1. fondaparinux 2.5 mg/0.5 ml syringe [**date range **]: one (1) syringe subcutaneous daily (daily). 2. acetaminophen 160 mg/5 ml solution [**date range **]: two (2) solutions po q8h (every 8 hours) as needed for pain. 3. calcium carbonate 500 mg tablet, chewable [**date range **]: one (1) tablet, chewable po tid w/meals (3 times a day with meals). 4. cholecalciferol (vitamin d3) 400 unit tablet [**date range **]: 2.5 tablets po daily (daily). 5. ferrous sulfate 300 mg (60 mg iron)/5 ml liquid [**date range **]: one (1) tab po daily (daily). 6. insulin regular human 100 unit/ml solution [**date range **]: see below units injection asdir (as directed): please resume prior sliding scale qachs. 7. levetiracetam 750 mg tablet [**date range **]: one (1) tablet po bid (2 times a day). 8. lansoprazole 30 mg tablet,rapid dissolve, dr [**last name (stitle) **]: one (1) tablet,rapid dissolve, dr [**last name (stitle) **] daily (daily). 9. prednisone 1 mg tablet [**last name (stitle) **]: seven (7) tablet po daily 10. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler [**last name (stitle) **]: 6-8 puffs inhalation q4h (every 4 hours) as needed for shortness of breath or wheezing. 11. ipratropium bromide 17 mcg/actuation aerosol [**last name (stitle) **]: six (6) puff inhalation q4h (every 4 hours). 12. ondansetron hcl (pf) 4 mg/2 ml solution [**last name (stitle) **]: one (1) injection injection q8h (every 8 hours) as needed for nausea. 13. white petrolatum-mineral oil 42.5-56.8 % ointment [**last name (stitle) **]: one (1) appl ophthalmic daily (daily) as needed for dry eyes. 14. terbinafine 1 % cream [**last name (stitle) **]: one (1) appl topical [**hospital1 **] 15. docusate sodium 50 mg/5 ml liquid [**hospital1 **]: five (5) ml po bid 16. senna 8.6 mg tablet [**hospital1 **]: one (1) tablet po bid 17. aspirin 325 mg tablet [**hospital1 **]: one (1) tablet po daily (daily). 18. chlorhexidine gluconate 0.12 % mouthwash [**hospital1 **]: one (1) ml mucous membrane [**hospital1 **] (2 times a day) as needed for oral care. 19. miconazole nitrate 2 % powder [**hospital1 **]: one (1) appl topical tid (3 times a day) for 1 weeks. discharge medications: 1. bisacodyl 5 mg tablet, delayed release (e.c.) [**hospital1 **]: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 2. senna 8.6 mg tablet [**hospital1 **]: one (1) tablet po bid (2 times a day) as needed for constipation. 3. docusate sodium 50 mg/5 ml liquid [**hospital1 **]: two (2) po bid (2 times a day) as needed for constipation. 4. calcium carbonate 500 mg tablet, chewable [**hospital1 **]: one (1) tablet, chewable po tid w/meals (3 times a day with meals). 5. cholecalciferol (vitamin d3) 400 unit tablet [**hospital1 **]: two (2) tablet po daily (daily). 6. ferrous sulfate 300 mg (60 mg iron)/5 ml liquid [**hospital1 **]: one (1) po daily (daily). 7. levetiracetam 750 mg tablet [**hospital1 **]: one (1) tablet po bid (2 times a day). 8. lansoprazole 30 mg tablet,rapid dissolve, dr [**last name (stitle) **]: one (1) tablet,rapid dissolve, dr [**last name (stitle) **] daily (daily). 9. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler [**last name (stitle) **]: 1-2 puffs inhalation q4h (every 4 hours) as needed for wheezing. 10. ipratropium bromide 17 mcg/actuation aerosol [**last name (stitle) **]: two (2) puff inhalation q4h (every 4 hours) as needed for wheezing. 11. aspirin 325 mg tablet [**last name (stitle) **]: one (1) tablet po daily (daily). 12. olanzapine 5 mg tablet [**last name (stitle) **]: one (1) tablet po tid (3 times a day). 13. fondaparinux 2.5 mg/0.5 ml syringe [**last name (stitle) **]: one (1) subcutaneous daily (daily). 14. trimethoprim-sulfamethoxazole 160-800 mg tablet [**last name (stitle) **]: one (1) tablet po qmowefr (monday -wednesday-friday). 15. insulin lispro 100 unit/ml solution [**last name (stitle) **]: one (1) subcutaneous asdir (as directed). 16. prednisone 1 mg tablet [**last name (stitle) **]: seven (7) tablet po daily (daily). 17. metoclopramide 10 mg tablet [**last name (stitle) **]: half tablet po qid (4 times a day) as needed for nausea. 18. citalopram 20 mg tablet [**last name (stitle) **]: one (1) tablet po daily (daily). 19. lidocaine 5 %(700 mg/patch) adhesive patch, medicated [**last name (stitle) **]: one (1) adhesive patch, medicated topical daily (daily): do not leave in place >12hours per 24 hour period. 20. tramadol 50 mg tablet [**last name (stitle) **]: 0.5 tablet po q6h (every 6 hours) as needed for pain. 21. ondansetron 4 mg iv q8h:prn nausea 22. lorazepam 1 mg iv q4h:prn agitation 23. vancomycin in dextrose 1 gram/200 ml piggyback [**last name (stitle) **]: one (1) intravenous q 12h (every 12 hours) for 2 days: day 1 = [**12-21**]. discontinue on [**2126-12-26**]. 24. acetaminophen 160 mg/5 ml solution [**date range **]: twenty (20) ml po q6h (every 6 hours) as needed for pain. ml discharge disposition: extended care facility: [**hospital6 459**] for the aged - macu discharge diagnosis: primary: -cellulitis, right foot . secondary: -copd s/p trach, on chronic prednisone, tracheomalacia [**2-11**] h/o tracheal stenosis -dm2 -diastolic chf -mild pulmonary htn -osteoporosis s/p mid-thoracic vertebral body fracture, hip fx, and r wrist fracture -chronic lbp - pt reports compression fractures from osteoporosis -hepatitis b -iron def. anemia -h/o cardiac arrest -h/o c diff colitis -h/o gastric and duodenal ulcers -h/o nephrolithiasis -h/o mrsa nasal swab, mrsa sputum cx discharge condition: alert, interactive. on ventilator. afebrile. discharge instructions: you were admitted with fevers and altered mental status. on discharge you were afebrile, alert, and interactive. your chronic pain was better controlled. you also had a cellulitis of your right foot, and were seen by podiatry and treated with a course of antibiotics for that (vancomycin iv, course to be completed on [**12-26**]). . please call your doctor or return to the hospital for fever >100.4, chest or abdominal pain, altered mental status/confusion, difficulty breathing, or other symptoms that concern you. . you were started on a new medication, to treat depression, called celexa. . you were not found to have c.difficile infection, so your oral vancomycin was discontinued. . you now have available to you: tramadol, lidocaine patch, and tylenol for treatment of your chronic back pain. . your sister, who is your healthcare proxy, determined that you were 'full code' for this hospitalization. followup instructions: n/a [**name6 (md) **] [**name8 (md) **] md [**md number(2) 2764**] completed by:[**2126-12-25**]",1
143,"admission date: [**2146-9-16**] discharge date: [**2146-10-7**] date of birth: [**2098-10-13**] sex: f service: medicine allergies: demerol / compazine / reglan / betadine surgi-prep / tape / iodine; iodine containing / vancomycin attending:[**first name3 (lf) 2195**] chief complaint: hypotension, septic shock major surgical or invasive procedure: esophagoduodenoscopy (egd) transesophageal echocardiography (tee) left femoral hickman line replacement history of present illness: patient is a 47 yo f with [**location (un) **] syndrome s/p colectomy, repeated small bowel resections, and resultant short gut syndrome on tpn since [**2123**] c/b with multiple line infections and clotted veins. she was recently admitted on [**2146-8-23**] to the [**hospital unit name 153**] for sepsis. although no clear source was found, she was streated iwht iv fluconazole and daptomycin for her history of fungemia and multiple line infections. she had a tee that was negative for endocarditis. she was discharged on [**2146-9-2**] on daptomycin and fluconazole. of note, during this hospitalization, she had new word-finding difficulties and a noncontrast head ct demonstrated a new interval focus of hypodensity in the l basal ganglia, concerning for acute to subacute ischemia, and new subtle hypodensity at the left cerebellum, also concerning for acute ischemia. however, she could not tolerate cts with contrast or mris so no further imaging was performed. neurology felt her symptoms did not correlate with the ct findings. today she presented to the ed with painful petechie all over her hands, feet, and legs. her mother took her vs this morning at 10am, which were 100.5, 119, 98/60, 28. she had bilious vomiting and was shaking. she was noted to have large petechiae on her entire body, including pams and soles. in the ed, initial vs: 98.5, 128, 98/64, 20, 96 on ra. she was dropping her sbp in 60s-70s, which somewhat responded to 3l ns. she received meropenam and is ordered for daptomycin and micafungin per id. ir has been notifed of new line needs and will take her case next. current vs are: afeb, 82/49, 112, 19, 97-100% on 4l. ros: denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, brbpr, melena, hematochezia, dysuria, hematuria. past medical history: ++ [**location (un) **] syndrome - diagnosed age 23 - total colectomy, end ileostomy [**2121**] - small bowel resection (multiple) secondary to recurrent polyposis - subsequent short gut syndrome - on tpn since [**2123**], [**9-/2131**] ++ benign cystadenoma - partial hepatectomy, [**2131**] ++ line-associated blood stream infections - her cvl in her l leg has been in place for at least 5 years, when she has had infections the line has been changed over a wire as pt has limited remaining access (l groin vessels and hepatic vessels are only usable vessels). - mssa, [**2127**] - [**first name5 (namepattern1) 564**] [**last name (namepattern1) 563**] [**12/2139**] - c. parapsilosis + coag neg staph, [**2-/2140**] - [**female first name (un) 564**] non-albicans, [**3-/2141**] - c.parapsilosis, [**9-/2142**] - k. pneumoniae, [**9-/2145**] --> resistant to cipro, cefuroxime, tmp/smx --> treated with meropenem [**date range (1) 110935**]/08 - line change due to positive blood cultures (?) [**10/2145**] --> had an echocardiogram that was abnormal as noted below coag neg staph [**1-/2146**] --> line changed over wire --> linezolid [**date range (1) 110936**] --> coag neg staph [**6-2**], no line change, on dapto till [**2146-6-28**] - admitted to [**hospital1 18**] [**2145-9-27**] with history of + urine for vre isolated on [**2145-9-8**] at healthcare [**hospital 4470**] hospital. ++ venous thrombosis/occlusion - failed access in r ij, r brachiocephalic - reconstructed ivc w/ kissing stent extensions into high ivc - stenting to r femoral, external iliac ++ gi bleed ++ hsv-1 ++ fibromyalgia ++ osteoporosis ++ scoliosis; h/o surgical repair ++ right hip fracture; orif [**2129**] ++ meniscal tears of knee; 4 prior surgeries, [**2133**] ++ total abdominal hysterectomy; bilateral salpingo-oophorectomy ++ dermoid cyst removal (small bowel, ovaries) ++ hepatic cyst adenoma; resected ++ cholecystectomy, [**2131**] . previous microbiology(selected positive results): [**2146-6-17**] ucx: klebsiella and pseudomonas (? contaminated) [**2146-6-10**] ucx: klebsiella [**2146-6-1**]: bcx: malassezia species. [**2146-2-24**] bcx: [**female first name (un) **] albicans social history: the patient lives with her mother in [**name (ni) 20157**], mass; mother helps her with her medical needs. pt also has pcas who she has hired to help with care. denies alcohol or tobacco. sister, [**name (ni) 3235**], is very involved in her care and likes to be updated frequently. family history: father and 6 of 8 siblings with [**location (un) **] syndrome. mother and relatives with htn and resulting cva. sister with breast cancer. her father's parents died of cancer. physical exam: t 98.1 bp 104/72 p 93 rr 20 o2sat 100% 2lnc gen: middle-aged woman, in mild discomfort heent: nc/at, eomi, mmm, supple neck, no lad chest: cta b/l, no wheezing/rales cv: rrr, nl s1s2, no m/r/g abd: soft, nt, nd, +bs, ostomy c/d/i ext: no c/c/e, +dp pulses access: l femoral hickman nonerythematous, nontender skin: dark petechiae on finger and toes pertinent results: admission labs [**2146-9-16**]: [**2146-9-16**] 12:45pm wbc-2.0* hgb-10.3* hct-31.6* plt ct-148*# [**2146-9-16**] 12:45pm neuts-64 bands-18* lymphs-14* monos-1* eos-2 baso-0 atyps-0 metas-0 myelos-1* [**2146-9-16**] 12:45pm hypochr-normal anisocy-occasional poiklo-occasional macrocy-normal microcy-occasional polychr-1+ ovalocy-occasional stipple-occasional [**2146-9-16**] 12:45pm pt-14.2* ptt-34.5 inr(pt)-1.2* [**2146-9-16**] 12:45pm glucose-90 urean-24* creat-1.5* na-135 k-4.4 cl-103 hco3-21* angap-15 [**2146-9-16**] 12:45pm alt-116* ast-121* alkphos-522* totbili-2.8* [**2146-9-16**] 12:45pm lipase-20 [**2146-9-16**] 12:45pm calcium-8.9 phos-2.2* mg-1.4* [**2146-9-16**] 12:48pm lactate-4.3* [**2146-9-16**] 05:27pm lactate-2.3* u/a: [**2146-9-16**] 02:00pm color-yellow appear-clear sp [**last name (un) **]-1.016 [**2146-9-16**] 02:00pm blood-mod nitrite-neg protein- glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-neg [**2146-9-16**] 02:00pm rbc-[**5-4**]* wbc-0-2 bacteri-rare yeast-none epi-0-2 [**2146-9-16**] 05:20pm color-yellow appear-clear sp [**last name (un) **]-1.012 [**2146-9-16**] 05:20pm blood-lg nitrite-neg protein-25 glucose-neg ketone-neg bilirub-sm urobiln-neg ph-5.0 leuks-neg [**2146-9-16**] 05:20pm rbc->50 wbc-0-2 bacteri-mod yeast-none epi-0-2 [**2146-9-16**] 05:20pm eos-negative [**2146-9-16**] 05:20pm hours-random creat-59 na-117 wbc trend: [**2146-9-16**] 12:45pm wbc-2.0* [**2146-9-17**] 03:43am wbc-8.8# [**2146-9-17**] 11:38am wbc-5.8 [**2146-9-18**] 01:38am wbc-8.3 [**2146-9-19**] 03:52am wbc-5.2 [**2146-9-20**] 04:58am wbc-4.5 [**2146-9-21**] 05:24am wbc-3.7* [**2146-9-22**] 06:57am wbc-4.2 [**2146-9-23**] 06:40am wbc-4.0 [**2146-9-24**] 05:34am wbc-6.2# [**2146-9-24**] 07:15am wbc-6.2 [**2146-9-25**] 05:02am wbc-4.9 [**2146-9-26**] 05:43am wbc-5.3 [**2146-9-27**] 05:53am wbc-4.5 [**2146-9-28**] 06:05am wbc-3.4* [**2146-9-29**] 05:01am wbc-3.4* [**2146-9-30**] 05:10am wbc-3.6* [**2146-10-1**] 05:58am wbc-3.2* [**2146-10-2**] 05:48am wbc-3.0* [**2146-10-3**] 04:20am wbc-2.8* [**2146-10-4**] 05:47am wbc-3.2* [**2146-10-5**] 07:29am wbc-2.4* [**2146-10-6**] 06:39am wbc-2.8* [**2146-10-7**] 06:05am wbc-3.0* other pertinent labs: [**2146-9-17**] 11:38am fibrino-336 [**2146-9-17**] 11:38am fdp-160-320* [**2146-9-18**] 07:28am fibrino-338 [**2146-9-17**] 03:43am blood hapto-99 [**2146-9-22**] 03:45pm aca igg-3.5 aca igm-6.6 [**2146-9-16**] 12:45pm alt-116* ast-121* alkphos-522* totbili-2.8* [**2146-9-17**] 03:43am alt-71* ast-51* ld(ldh)-279* alkphos-323* totbili-0.4 [**2146-9-18**] 01:38am alt-55* ast-34 alkphos-271* totbili-0.7 ck monitoring on daptomycin: [**2146-9-22**] 06:57am ck(cpk)-14* [**2146-9-30**] 05:10am ck(cpk)-10* [**2146-10-6**] 06:39am ck(cpk)-17* microbiology: [**2146-9-16**] bcx: klebsiella pneumoniae | ampicillin/sulbactam-- 16 i cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ =>64 r ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- 16 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s [**2146-9-16**] ucx: negative [**2146-9-16**] bcx: no fungus/mycobacterium [**2146-9-16**] bcx: no growth [**2146-9-16**] mrsa screen: negative [**2146-9-16**] ucx: negative [**2146-9-16**] catheter tip: negative 10/24-26/09 bcx: no growth studies: [**2146-9-16**] ekg: sinus rhythm. overall, low qrs voltages. compared to the previous tracing of [**2146-8-22**] low voltages are now seen in the precordial leads [**2146-9-16**] cxr: improved aeration of bilateral bases with some residual atelectasis. stable low lung volumes and elevation of right hemidiaphragm [**2146-9-17**] ruq u/s: stable prominence of the common bile duct with trace free fluid in [**location (un) 6813**] pouch. these findings are nonspecific and clinical correlation is recommended. [**2146-9-17**] cxr: there is unchanged appearance of the vascular stents. the cardiomediastinal silhouette is unchanged. there is slight increase in the right pleural effusion with potential increase in the right basal atelectasis but note is made that overlying devices are projecting over the right chest and the exam should be repeated for precise evaluation of the right hemithorax [**2146-9-17**] ct abd/pelvis 1. no evidence of large retroperitoneal bleed. 2. extensive perivascular fat stranding and small amount of free fluid within the pelvis which measures simple. 3. right lower lobe consolidation concerning for infection and less likely atelectasis. small bilateral pleural effusions. 4. prominent mesenteric and retroperitoneal lymphadenopathy, not significantly changed. [**2146-9-19**] tte: atrial septal defect with right-to-left flow at rest. moderate tricuspid regurgitation. mild pulmonary artery systolic hypertension. if clinically indicated, a tee would be better able to define the size/site of the atrial septal defect. lvef >55%. [**2146-9-21**] cxr: in comparison with the study of [**9-17**], there is little overall change. vascular stents are again seen. extensive right pleural effusion with atelectatic change in the lower lung is again seen. less prominent opacification is again seen at the left base [**2146-9-23**] cta chest: 1. limited study with no evidence of central pulmonary embolism. 2. waxing and [**doctor last name 688**] multifocal peribronchial and peripheral nodular opacities, most likely infectious or inflammatory in etiology. 3. atelectasis in the right lower lobe, mostly due to persistent elevation of the right hemidiaphragm. 4. mediastinal lymphadenopathy, which could be reactive [**2146-10-4**] tee: patent foramen ovale with bidirectional shunting at rest and anatomy not ideally suited for percutaneous closure. no intracardiac thrombus seen. [**2146-10-4**] ue/le b/l lenis: patent visualized left and right subclavian veins patent left common femoral vein, containing venous catheter. persistent occlusion of the right common femoral vein. discharge labs [**2146-10-7**]: [**2146-10-7**] 06:05pm wbc-3.0* hgb-9.1* hct-27.1* plt ct-288*# [**2146-10-7**] 06:05pm glucose-113 urean-23 creat-0.8 na-139 k-4.1 cl-107 hco3-25 angap-11 brief hospital course: ms. [**known lastname 1557**] is a 47 year old woman with h/[**initials (namepattern4) **] [**last name (namepattern4) **] syndrome, multiple abdominal surgeries, resultant short gut syndrome, on chronic tpn, who presented with sepsis and paradoxical emboli. # klebsiella bacteremia - the patient was admitted to the micu with sepsis, likely [**12-27**] to line infection and was started on daptomycin, meropenem, ciprofloxacin, and micafungin empirically. her left femoral hickman was replaced by ir on [**9-16**]. initial bcx grew klebsiella, sensitive to ceftriaxone, so the patient was started on ceftriaxone - last day [**2146-10-14**]. she was also given daptomycin and fluconazole from a prior infection until [**2146-10-7**]. she was hemodynamically stable and transferred to the floor with no issues. she was afebrile with no increase in wbc count during her hospitalization. she tolerated the antibiotics well. blood cultures from [**date range (1) 51017**] were negative. ucx were negative as well. the patient had a tte on [**2146-9-19**] to look for vegetations - no vegetations were noted. the patient is to follow up in [**hospital **] clinic upon discharge. # anemia: the patient was transfused with 2u prbc in the micu on [**9-17**] for hct 21.4%, with improvement to 29.1%. ct showed no large rp bleed. the patient's hct remained stable during her hosptialization with no further requirement for transfusion. # asd: the patient has a known asd, first noted on echo in [**2139**]. the tte on [**2146-9-19**] showed new r->l shunt, thought to be [**12-27**] to increased pulmonary pressures from untreated pe from [**3-3**]. she was unable to undergo cardiac mri for better characterization, as she has b/l rods implanted in her femurs for prior leg fractures. she had a tee performed on [**2146-10-4**] that better characterized the asd. it was determined to be suboptimal for closure at this point, so the patient was started on anticoagulation to treat her pe and lower pulmonary pressures. she can be re-evaluated in the future if she continues to have paradoxical emboli. # dysphagia: the patient has noted intermittent symptoms of choking for the past year. she was scheduled for outpatient egd for further evaluation, but has missed all of the appointments in the past year [**12-27**] to hospitalizations. she also failed conscious sedation on one occasion as an outpatient. she was able to undergo egd under general anesthesia while an inpatient. she was found to have an esophageal stricture [**12-27**] to reflux esophagitis. she was started on a ppi [**hospital1 **] for treatment. # pe/multiple line-related thromboses: the patient has a h/o of pe from [**2146-2-23**] that was untreated [**12-27**] to failure of ac with coumadin (supratherapeutic inr [**12-27**] to interactions with abx) and lovenox (adverse reaction - painful welts developed on arms and abdomen). she had been on plavix for the past several months. she was admitted with painful petechiae on her fingers/toes and had episodes of word finding difficulties. it is likely that the clots from her lines were traveling through the asd with the new r->l shunt. the asd was determined to be difficult to close, so anticoagulation was re-addressed. the patient was started on fondaparinux for anticoagulation with instructions to monitor closely for any adverse reactions. she also has outpatient follow up scheduled with hematology to determine the best course of anticoagulation. further work-up for other causes of increased clotting was not done, as the patient has clear risks for clot formation from her multiple stents and indwelling line. # leukopenia: the patient was noted to have leukopenia - wbc ~3, possibly from drug reaction. since daptomycin and fluconazole were being discontinued only several days after the wbc was noted to be decreasing, it was decided to continue these drugs until [**2146-10-7**]. wbc on discharge was 3.0. she should have her wbc closely monitored as an outpatient. medications on admission: fentanyl 150 mcg/hr patch 72 hr clopidogrel 75 mg po daily ondansetron 4 mg rapid dissolve po every 4 hours prn fluconazole 400 mg/200 ml daily daptomycin 275 mg q24h lorazepam 0.5 mg po q6h orn morphine 10-20 mg po q4h as needed for pain. discharge medications: 1. outpatient lab work please draw weekly cbc with diff, bun, cr, ast, alt, alkphos, tbili, ck while the patient is on antibiotics. please fax results to dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 111**] at [**telephone/fax (1) 432**]. 2. fondaparinux 5 mg/0.4 ml syringe sig: five (5) mg subcutaneous daily (daily). disp:*30 mg* refills:*0* 3. fentanyl 75 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 4. morphine concentrate 20 mg/ml solution sig: 10-20 mg po every four (4) hours as needed for pain. 5. ethanol (ethyl alcohol) 98 % solution sig: two (2) ml intravenous daily (daily). 6. heparin flush (10 units/ml) 2 ml iv prn line flush tunneled access line (e.g. hickman), heparin dependent: flush with 10 ml normal saline followed by heparin as above daily and prn per lumen. 7. ceftriaxone 1 gram recon soln sig: one (1) g intravenous once a day for 7 days: end [**2146-10-14**]. disp:*7 g* refills:*0* 8. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every four (4) hours as needed for nausea. 9. lorazepam 0.5 mg tablet sig: one (1) tablet po every six (6) hours as needed for anxiety. 10. 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 with service facility: diversified vna and hospice discharge diagnosis: primary diagnosis klebsiella bacteremia esophageal stricture secondary to reflux esophagitis secondary diagnosis pulmonary embolism atrial septal defect [**location (un) **] syndrome discharge condition: stable, improved, afebrile discharge instructions: you were admitted to the hospital with an infection in your blood. your left femoral hickman line was replaced by interventional radiology, and you were started on antibiotic treatment. you have responded well to the antibiotics and have not had any fevers. you were also admitted with painful fingertips and toes, which was caused by blood clots. you had an echocardiogram, which showed that the blood has started shunting from the right to the left side of the heart. this is because of increased pressure in your lung, which is likely due to a blood clot (pulmonary embolus) that has been untreated in your lung since [**2146-2-23**]. you were unable to tolerate treatment with coumadin in the past because it made your blood too thin. lovenox gave you painful welts on your arms and abdomen. you underwent an egd and tee during this hospitalization to evaluate your esophagus and the hole in your heart. you were found to have a stricture in the esophagus, which has been causing you difficulty swallowing for the past year. this can be treated with acid blocking medication. unfortunately, the hole in your heart is not going to be easily repaired. it was thought to be safer to start blood thinners (fondaparinux) to treat the blood clot in your lungs, which will hopefully decrease the pressure in your lungs. the following changes have been made to your medications: 1. start fondaparinux 5mg subcutaneously daily - this is a blood thinner that will help treat the blood clot in your lung, as well as prevent more blood clots from forming. please monitor closely for any adverse reactions to this medication, as you have had an adverse reaction to lovenox (a similar medication) in the past. 2. take ceftriaxone until [**2146-10-14**] to complete treatment for your infection. 3. take pantoprazole twice daily to treat reflux esophagitis if you experience bleeding, fevers, chills, shortness of breath, chest pain, abdominal pain, nausea, vomiting, lightheadedness, or any other concerning symptoms, please call your primary care doctor or return to the emergency department. it was a pleasure meeting you and taking part in your care. followup instructions: the following appointments that have already been scheduled for you: primary care appointment: [**last name (lf) **],[**first name3 (lf) **] a. [**telephone/fax (1) 75498**] date/time: [**2146-10-13**] 3:30pm hematology: md: [**first name8 (namepattern2) **] [**last name (namepattern1) 6944**] date and time: wednesday, [**11-2**], 4:40pm location: [**location (un) **], [**location (un) 436**] phone number: [**telephone/fax (1) 6946**] infectious disease: provider: [**first name8 (namepattern2) **] [**last name (namepattern1) **], md phone:[**telephone/fax (1) 457**] date/time:[**2146-11-4**] 11:30",1
144,"admission date: [**2126-12-9**] discharge date: [**2126-12-16**] date of birth: [**2075-12-30**] sex: f service: medicine allergies: sulfa (sulfonamide antibiotics) / dapsone / simvastatin / efavirenz attending:[**first name3 (lf) 5810**] chief complaint: sob, cough major surgical or invasive procedure: left internal jugular central line placement on [**2126-12-9**] bronchoscopy (scope of your lung) on [**2126-12-13**] history of present illness: 50yo female w/ hiv, hcv, depression here with 6 months of malaise, weight loss (~15-20 lbs), 3-4 weeks of cough and worsening sob. cough is persistent and productive of scant white sputum. she has had sob on exertion and fevers with shaking chills for 2 weeks. no n/v/d or change in color of her bms. no chest pain, edema or dysuria. no recent abx and no sick contacts, has not been hospitalized for quite some time. has had a 15-20lb weight loss and decreased energy over the last 6 months. today she saw her pcp, [**name10 (nameis) 1023**] ordered a c-xray showing a rul 6cm mass. in the ed, initial vitals were 102.2 120 107/68 18 100% 3l ra. scant wheezes throughout, dullness to percussion at rll. initially looked well. pressures dropped from 107/68 to a map of 50 even after 2l fluid. lactate 1.3. given vanc, levaquin, cefepime. no pericardial effusion on bedside echo. placed l ij after failed r ij. hct 25. sent sv02. map 72 prior to transfer. satting well on 2l. on the floor, patient resting comfortably. she endorses fatigue and generally feeling depressed. she was born in [**location (un) 86**] and has lived here most of her life. she has travelled with her partner several times to [**name (ni) 101361**], [**country 21363**]. no other sick contacts. she has been post-menopausal for one year. all other ros negative. past medical history: - hiv not on antiretrovirals, cd4 count in [**2124**] was 163 - during hospitalization in [**12/2126**], cd4 count 124 and hiv viral load 574k/ml - chronic hepatitis c - depression - leiomyoma of the uterus - condyloma acuminatum - oral hsv social history: has a partner [**name (ni) **], who is also her hcp. [**name (ni) **] travelled several times to medillin, [**country 21363**] in the past several years, last in [**2124**]. works as a personal trainer at a gym. - tobacco: has smoked on and off since age 14, currently trying to quit. - alcohol: minimal etoh - illicits: none since [**2103**] family history: no h/o lung disease except a grandfather w/ emphysema physical exam: admission exam: vitals: t 96.2 hr 87 bp 112/74 rr 18 o2sat: 100%ra general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear, lul cold sore neck: supple, jvp not elevated, no lad, l ij c/d/i lungs: focal rhochi at r base, w/ surrounding crackles and dullness to percussion. 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 neuro: aaox3, cns [**3-16**] intact, strength and sensation grossly nl. discharge exam: 97.9 120/88 99 20 97% ra thin woman, breathing comfortably. tired appearing but appropriate and pleasant. lungs clear to auscultation with good air movement, no crackles or wheezes. pertinent results: admission labs: [**2126-12-9**] 04:52pm blood wbc-9.3 rbc-2.96* hgb-8.7* hct-25.2* mcv-85 mch-29.4 mchc-34.6 rdw-13.9 plt ct-205 [**2126-12-9**] 04:52pm blood neuts-71.3* lymphs-21.5 monos-6.4 eos-0.6 baso-0.3 [**2126-12-9**] 04:52pm blood wbc-9.3 lymph-22 abs [**last name (un) **]-2046 cd3%-88 abs cd3-1793 cd4%-6 abs cd4-124* cd8%-80 abs cd8-1640* cd4/cd8-0.1* [**2126-12-9**] 04:52pm blood ret aut-1.1* [**2126-12-9**] 04:52pm blood glucose-117* urean-20 creat-1.4* na-130* k-4.8 cl-99 hco3-23 angap-13 [**2126-12-10**] 04:25am blood alt-20 ast-34 alkphos-52 totbili-0.2 [**2126-12-9**] 04:52pm blood iron-14* [**2126-12-9**] 04:52pm blood caltibc-157* ferritn-883* trf-121* [**2126-12-9**] 10:03pm blood type-[**last name (un) **] po2-63* pco2-33* ph-7.39 caltco2-21 base xs--3 comment-green top [**2126-12-9**] 05:08pm blood lactate-1.3 k-4.7 [**2126-12-9**] 10:03pm blood o2 sat-88 [**2126-12-9**] 10:03pm blood freeca-0.96* urine: [**2126-12-9**] 08:00pm urine color-yellow appear-clear sp [**last name (un) **]-1.010 [**2126-12-9**] 08:00pm urine blood-neg nitrite-neg protein-100 glucose-neg ketone-neg bilirub-neg urobiln-2* ph-6.0 leuks-neg [**2126-12-9**] 08:00pm urine rbc-2 wbc-0 bacteri-few yeast-none epi-0 other pertinent labs: beta-glucan: 280 pg/ml cryptococcal ag: negative galactomannan: pending histoplasma ag: pending coccidio ab: pending microbiology: [**2126-12-9**] bcx: no growth x2 [**2126-12-10**] bcx: no growth x2 [**2126-12-12**] bcx: pending, ngtd [**2126-12-13**] bcx: pending, ngtd [**2126-12-13**] fungal bcx: pending, preliminary no fungal growth [**2126-12-9**] ucx: no growth [**2126-12-9**] mrsa screen: negative [**2126-12-9**] legionella ag: negative [**2126-12-10**] sputum cx: multiple organisms consistent with oropharyngeal flora. [**2126-12-10**] sputum cx: gram stain: <10 pmns and <10 epithelial cells/100x field. multiple organisms consistent with oropharyngeal flora. quality of specimen cannot be assessed. respiratory culture: sparse growth commensal respiratory flora. acid fast smear: no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): pending [**2126-12-11**] sputum cx: legionella culture (preliminary): no legionella isolated. acid fast smear: no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): pending [**2126-12-12**] sputum cx: acid fast smear: no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): pending immunoflourescent test for pneumocystis jirovecii (carinii): negative for pneumocystis jirovecii (carinii). [**2126-12-13**] bal x2: 1. left upper lobe -> gram stain: 1+ pmns, no microorganisms seen. respiratory culture: no growth, <1000 cfu/ml. acid fast smear (preliminary): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): pending fungal culture (preliminary): pending immunoflourescent test for pneumocystis jirovecii (carinii): negative for pneumocystis jirovecii (carinii). 2. right upper lobe -> immunoflourescent test for pneumocystis jirovecii (carinii): negative for pneumocystis jirovecii (carinii) [**2126-12-13**] right upper lobe mass: gram stain: no polymorphonuclear leukocytes seen. no microorganisms seen. tissue (final [**2126-12-16**]): no growth. anaerobic culture (preliminary): no growth. acid fast smear (preliminary): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): pending fungal culture (preliminary): pending potassium hydroxide preparation (preliminary): immunoflourescent test for pneumocystis jirovecii (carinii) (final [**2126-12-15**]): negative for pneumocystis jirovecii (carinii). [**2126-12-13**] ebus tbna level 7 (biopsy): gram stain: 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. tissue (preliminary): gram positive bacteria. rare growth. anaerobic culture (preliminary): no anaerobes isolated. acid fast smear (preliminary): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): pending fungal culture (preliminary): pending potassium hydroxide preparation (preliminary): pending immunoflourescent test for pneumocystis jirovecii (carinii) (final [**2126-12-15**]): negative for pneumocystis jirovecii (carinii). studies: [**2126-12-9**] cxr: single ap upright portable view of the chest was obtained. the left internal jugular central venous catheter is seen, terminating at the lateral aspect of where the mid svc would be expected to be located. no pneumothorax is seen. right upper lung consolidation is worrisome for pneumonia. there may also be subtle patchy left base opacity. no pleural effusion is seen. cardiac and mediastinal silhouettes are unremarkable. [**2126-12-10**] ct chest: 1. geographic ground-glass opacities with upper lobe predominance, left greater than right with relative peripheral sparing. in this patient with hiv and cd4 count below 200, this is concerning for pcp [**name initial (pre) 1064**]. 2. superimposed mass-like consolidation in the right upper lobe would be highly atypical for pcp. [**name10 (nameis) **] could thus be explained by a second infectious process, including community acquired bacterial pneumonia. though the imaging findings do not specifically suggest fungal infection or tuburculosis, these should be considered in this immunocompromised patient until ruled out. alternatively, this rul consolidation could also represent malignancy, such as lymphoma. the presence of enlarged mediastinal, axillary, and cervical lymph nodes support consideration of this latter diagnosis. 3. small pleural effusions with diffuse interlobular septal and bronchial wall thickening, suggesting volume overload. this could account for a degree of the ground-glass opacity as well. [**2126-12-11**] ct abd/pelvis: 1. extensive periportal, retrocrural, paraaortic, and aortocaval adenopathy. differential would include lymphoma, tb, or infection. 2. bibasal pleural effusions with bibasal atelectasis. 3. bilateral renal cortical scarring. 4. small amount of air within the bladder. suggest correlation with history of any foley catheter insertion or instrumentation. [**2126-12-13**] echocardiogram: the left atrium and right atrium are normal in cavity size. the estimated right atrial pressure is 0-5 mmhg. 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 ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: normal global and regional biventricular systolic function. no clinically-significant valvular disease seen. discharge labs: brief hospital course: ms. [**known lastname 100653**] is a 50 year old woman w/ aids (cd4 124), hcv, and depression, who was admitted with 3 weeks of worsening cough and fevers, found to have rul opacity and ground glass opacity in ct chest that is concerning for pcp. [**name10 (nameis) **] was treated with azithromycin and ceftriaxone x7 days for community acquired pneumonia, and had bronchoscopy and bal done on [**2126-12-13**]. patient was started on empiric treatment for pcp. [**name10 (nameis) **] respiratory status remained stable in the hospital. # community acquired pneumonia: given patient's immunocompromised status, broad differential was maintained initially for her cough and fevers and she was covered broadly in the ed with vancomycin, cefepime and levofloxacin. however, given that patient has not been near healthcare facilities, her antibiotics were narrowed to ceftriaxone and azithromycin and she remained clinically stable on that regimen. patient was ruled out for tuberculosis with 3 negative acid fast bacilli smears (given her history of travel to [**country 21363**]). her beta d-glucan was found to be elevated, with increased suspicion for fungal process (pcp, [**name10 (nameis) **] or coccidio). she was initially started on empiric pcp treatment with clindamycin and primaquine after her bronchoscopy was done, but when her pcp dfa from bal and tissue biopsy came back negative, they were discontinued. her pcp dfa from both sputum and bal have been all negative. histoplasma antigen and coccidio antibodies are pending at the time of discharge. her legionalla urine antigen and sputum culture are negative. # right upper lobe lung mass and lymphadenopathy: possibly related to her infection, but concerning for malignancy given her history of night sweats and weight loss. biopsy of lymph node was done during bronchoscopy and the results from the biopsy are pending. # hiv/aids: patient has been on haart in the past, but discontinued them for various reasons, including side effects. she has been out of contact with physicians for some time now. cd4 count during this hospitalization was 124, down from 163 in [**2124**]. hiv vl was 574,000 copies/ml. id was consulted and recommended testing for cryptococcus, histoplasma, cocciodiomycosis, aspergillosis (galactomannan) and ruling out pcp and tb with sputum studies. patient reported interest in restarting haart with her primary care physician, [**last name (namepattern4) **]. [**last name (stitle) **]. given her cd4 count during this hospitalization, patient was discharged on dapsone as pcp [**name initial (pre) 1102**] (adverse reaction to dapsone listed as headache, but patient does not recall the reaction and is willing to try it). # anemia: after fluid resuscitation, patient's hct was found to be 21.7, with unclear baseline. iron studies were done and it was suggestive of anemia of chronic inflammation. she had no evidence of acute blood loss. patient spiked a fever prior to transfusion, so it was held off. repeat hct was found to be 23 and it remained stable afterwards, so she was never transfused. # elevated bnp: given ground glass opacity and negative pcp [**name9 (pre) 97174**], bnp was checked for possibility of pulmonary edema from heart failure and was found to be elevated. echocardiogram was done and did not show any systolic or diastolic dysfunction. possibly related to rapid fluid resuscitation patient received in the emergency room. # acute renal failure: cr 1.4 on admission, up from baseline 1.0. resolved with fluids. # hyponatremia: na 130 on admission - likely hypovolemic, improved with ivf. # cold sore: started on po acyclovir and completed 7 day course. transitional issues: [ ] appointment with dr. [**last name (stitle) **] made for [**12-18**]. patient will need to discuss with her pcp about restarting [**name9 (pre) 2775**]. [ ] pending labs: [**name9 (pre) **], coccidio, galactomannan [ ] pending results from bal/biopsy: fungal cultures/afb cultures [ ] pathology pending from bronchoscopy biopsy medications on admission: none. discharge medications: 1. multivitamin tablet sig: one (1) tablet po once a day. 2. dapsone 100 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary diagnosis: community acquired pneumonia acquired immune deficiency syndrome secondary diagnosis: human immunodeficiency virus discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. [**known lastname 100653**], it was a pleasure to take care of you at [**hospital1 827**]. you were admitted because of your shortness of breath, cough and weight loss. because of your low blood pressure, you were given iv fluid and initially admitted to the icu for monitoring. you were given antibiotics for community-acquired pneumonia and several studies were sent out to test for various infectious causes. you had a bronchoscopy to get samples from different parts of your lung and the results from that are still pending. these new medications were started for you: - dapsone 100 mg tablet: one tablet by mouth daily for prophylaxis of pcp. [**name10 (nameis) **] you experience any side effects from this medication, please contact dr. [**last name (stitle) **] before discontinuing it on your own. followup instructions: name: [**last name (lf) **],[**first name3 (lf) **] j. location: [**hospital1 641**] address: [**location (un) **], [**location (un) **],[**numeric identifier 2260**] phone: [**telephone/fax (1) 3530**] when: wednesday, [**2126-12-18**]:20 am *please discuss the possibility of seeing a pulmonary specialist with dr. [**last name (stitle) **].",1
145,"admission date: [**2115-5-20**] discharge date: [**2115-5-29**] date of birth: [**2062-3-10**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**first name3 (lf) 2817**] chief complaint: sob major surgical or invasive procedure: l thoracentesis x2 history of present illness: 53 y/o f h/o hiv (no haart [**4-6**] cd4 490, vl > 100k), stage iv nsclc presented to the ed with sob x10 days with progressive doe, orthopnea and cough productive of occasional sputum. . in the ed patient had cxr and cta that demonstrated no pe, but significant progression of disease with enlarging r-hilar mass extending to the subcarinal area with lymphadenopathy and metastases. small pericardial effusion. . on floor patient remained hypoxic with persistent o2 requirement of 3l. had transient episodes of desaturation without clear explanation. team felt pleural effusion likely contributing to hypoxia. thoracentesis performed on [**5-22**] w/ removal of 1.4l of fluid from chest and again [**5-26**] removing 1200cc of bloody fluid w/o complication. patient underwent pleurodesis on am prior to arrival in icu. that afternoon patient became increasingly hypoxic with desat to 86%, tach to 120-130s. cxr looks a bit better. gave nebs and mso4, ativan 1mg. on nrb now, abg with hypoxia. ekg unchanged. admitted to the icu for mgmt of hypoxia. . ros: (+) sob, sick contacts (-) f/c, n/v/d, bowel/bladder changes. past medical history: ponch # stage iv nsclc (dx [**2114-12-5**]) - s/p pigtail drainage [**3-2**] malignant pericardial effusion - s/p carboplatin, gemcitabine x 4 cycles (last in [**2115-3-5**]) c/b neutropenia, thrombocytopenia . pmh # hiv ([**2115-3-20**]: cd4 471, vl >100,000) - no haart - no h/o oi # asthma # anemia # depression social history: # personal: lives with boyfriend # tobacco: no current. past use averaging 1pack/3 days # alcohol: no current # recreational drugs: cocaine abuse per omr. family history: noncontributory physical exam: # vs t 98.1 bp 115/80 hr 113 rr 22 o2 99%4l . gen: nad heent: ncat, perrl, eomi, op clear, mmm cv: rrr, s1/s2, no m/r/g. chest: significantly decreased breath sounds at l fields; mild crackles at right; globally diminished. abd: soft, ntnd, bs+, no hsm. ext: no edema, wwp neuro: cn ii-xii grossly intact pertinent results: # cta chest w&w/o c&recons, non-coronary [**2115-5-20**] 10:21 pm 1. no pe. 2. extensive progression of disease with now large left pleural effusion, enlarging right hilar mass extending to the subcarinal region with associated lymphadenopathy and innumerable pulmonary metastases. small pericardial effusion. . # chest (portable ap) [**2115-5-20**] 9:02 pm new large left pleural effusion, and associated left lower lobe opacity which may represent atelectasis versus underlying consolidation. . # chest (pa & lat) [**2115-5-21**] 10:55 am status post thoracocentesis with decrease in left pleural effusion and no pneumothorax. . # mr head w & w/o contrast [**2115-5-21**] 10:04 am 1. scattered subcentimeter enhancing lesions predominantly at the [**doctor last name 352**]/white matter junction are worrisome for infection/toxoplasmosis versus metastatic disease and clinical correlation is advised. 2. marrow signal from the cervical spine is unusual with loss of normal signal on t1, this is a nonspecific finding and may represent skeletal metastases and a bone scan would be helpful for further evaluation. . # tte [**2115-5-21**] at 12:47:29 pm the left atrium is elongated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. there is abnormal septal motion/position. 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. the pulmonary artery systolic pressure could not be determined. there is a small loculated pericardial effusion around the right atrium. . impression: mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. small pericardial effusion around right atrium (largest diameter 1.0 cm) . it appears trivial around the remainder of the heart. compared with the prior study (images reviewed) of [**2115-4-10**], the pericardial effusion around the right atrium is better seen. otherwise, the findings are similar. . # pleural fluid [**2115-5-21**]: positive for malignant cells. consistent with metastatic non-small cell carcinoma (nscc). . # chest (pa & lat) [**2115-5-22**] 8:53 am: interval reaccumulation of left pleural effusion. . # bone scan [**2115-5-22**]: no evidence of osseous metastases; bladder uptake obscurs the central pelvis. . # chest (pa & lat) [**2115-5-24**] 11:38 am large left pleural effusion has increased since [**5-22**], producing more rightward mediastinal shift, secondary atelectasis in both the left lower lung and the central right lung. no pneumothorax. cardiac silhouette is obscured but there has been a slight increase in caliber of mediastinal veins suggesting elevated central venous pressure. tip of the right subclavian line ends low in the svc. multiple lung nodules are largely obscured by atelectasis and effusion. . # cta chest w&w/o c&recons, non-coronary [**2115-5-25**] 11:24 pm 1. no evidence of pulmonary embolism. 2. further interval increase in size of left-sided pleural effusion. 3. large right hilar mass extending into the subcarinal region and associated lymphadenopathy and innumerable pulmonary metastases. . # chest (portable ap) [**2115-5-26**] 7:33 am: increasing left effusion with mediastinal shift. . # chest (portable ap) [**2115-5-26**] 10:10 am: reduction in left effusion. no pneumothorax. #le usd: [**2115-5-27**]: impression: no evidence for dvt. #tte [**2115-5-28**]: there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (lvef>55%). right ventricular chamber size and free wall motion are normal. there is mild pulmonary artery systolic hypertension. there is a small to moderate pericardial effusion anterior and posterior to the atria but very small anterior to the rv. there is brief right atrial diastolic collapse. compared with the prior study (images reviewed) of [**2115-5-21**], the amount of pericardial effusion has increased. the is no clear echocardiographic evidence of tamponade. #kub [**2115-6-26**]: impressions: no intra-abdominal free air. no evidence of obstruction. brief hospital course: 53f h/o hiv (no haart, [**4-6**] cd4 490, vl > 100k), stage iv nsclc, with l pleural effusion per ct. . # sob: thought secondary to progression of her underlying disease and recurrent pleural effusions. patient had repeat thoracentesis x2 on the floor as per hpi and later pleurodesis after the effusions recurred. hypoxia post-pleurodesis thought [**3-2**] to disease progression vs. adverse reaction to talc used on pleurodesis. patient was increasingly tachypneic without relief after bronchodilators or lasix. discussion was had with family and patient who agreed with plan for no-intubation. briefly tried on bipap but was persistently tachypneic. after much discussion patient and family opted to be comfort measures only. patient was made cmo and passed approximatley 12-24 hours thereafter. . # brain mets: new brain mets per mri head with gad. - [**5-22**]: rad onc consult pending for question whole brain xrt - [**5-23**]: holding xrt pending chest treatment. toxo igg, igm pending but unlikely toxo given last high cd4 count; however, current cd4 359 (viral load pending) - [**5-24**]: held whole brain xrt pending chest xrt completion. - further treatments deferred. . # ?osseous progression: bone scan ordered, pending for [**5-22**]. - [**5-23**]: pending official read. - [**5-24**]: no evidence of osseous metastases; bladder uptake obscurs the central pelvis. - further work-up deferred. . # stage iv nsclc: held chemotherapy in acute illness. - [**5-24**]: alimta holding until after xrt. . # anemia: hct 29. consent, type/screen. . # hiv: last cd4 490, vl >100,000; no haart. repeat cd4, vl. - [**5-24**]: pending vl. cd4 359 (decreasing). . # depression: continued on outpatient quetiapine, citalopram. medications on admission: seroquel 100 mg [**hospital1 **] citalopram 10 mg daily ibuprofen 200 mg, [**1-30**] tab tid prn albuterol 90 mcg/actuation aerosol inhaler 1-2 puffs inh prn ipratropium hfa 17 mcg/actuation aerosol inhaler 1 puff inh q6h prn . all: nkda discharge medications: none. discharge disposition: expired discharge diagnosis: primary diagnosis # stage iv nsclc (dx [**2114-12-5**]) . secondary diagnosis # hiv # asthma # depression discharge condition: deceased discharge instructions: none. followup instructions: none.",1
146,"admission date: [**2161-8-2**] discharge date: [**2161-8-4**] service: medicine allergies: epinephrine attending:[**first name3 (lf) 443**] chief complaint: shortness of breath major surgical or invasive procedure: none history of present illness: the patient is a [**age over 90 **] year old man with a past medical history of cad s/p mi , chf, a-fib and cva who had an episode of chest pressure this morning after breakfast. he was in his usual state of health prior to this event. the pressure radiated up his sternum but did not feel like his normal heartburn. durring that episode the also became very fatigued. he went to the ed as the pressure did not relieve with rest. he was found to be in a wide complex tach with hr of 180 and bp of 80/50 per the osh ed report. he was given a bolus of amiodarone 150 and recieved two shocks (50 jouls). he then went back into sinus rhythm followed by slow a-fib. he was then transffered to [**hospital1 18**]. ros + lightheadedness, fatigue. . cardiac review of systems is notable for absence, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope. past medical history: chf cardiomyopathy atrial fibrillation cad s/p mi [**2129**] cva [**2159**] goiter (dr. [**last name (stitle) 6467**] anemia (iron deficiency) s/p herpes zoster w/ post herpetic neuralgia diverticulosis paget's disease of the bone chronic sinusitis gib [**2148**] + h. pylori --> treated. . cardiac risk factors: no dm, no htn, no hyperlipidemia. . social history: pt lives with his wife who is very ill. they have 24 hour nursing assistance. quit smoking at age 60. family history: non-contributory. physical exam: vs: t: 96.8, bp: 102/41, hr: 53, rr: 20, o2 98% on ra gen: elderly male in nad, resp or otherwise. oriented x3. mood, affect appropriate. pleasant. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. neck: supple with jvp of cm. cv: s1, s2. no s4, no s3. irregularly irregular. 3/6 sem at the apex suggestive of mr. chest: no crackles, wheeze, rhonchi. abd: soft, nt/nd +bs. ext: no c/c/e. pertinent results: [**2161-8-2**] 01:14pm wbc-7.3 rbc-3.73* hgb-10.8* hct-32.4* mcv-87 mch-28.9 mchc-33.2 rdw-14.4 neuts-81.1* lymphs-14.6* monos-3.8 eos-0.3 basos-0.2 pt-13.7* ptt-25.6 inr(pt)-1.2* tsh-<0.02* free t4-1.3 calcium-10.1 phosphate-2.7 magnesium-2.0 ck-mb-23* mb indx-21.7* ctropnt-0.32* ck(cpk)-106 glucose-147* urea n-23* creat-1.0 sodium-136 potassium-4.8 chloride-104 total co2-21* anion gap-16 . [**2161-8-2**] 08:35pm ck-mb-22* mb indx-21.2* ctropnt-0.73* [**2161-8-2**] 08:35pm ck(cpk)-104 [**2161-8-3**] 05:39am ctropnt-0.51* . chest (portable ap) study date of [**2161-8-2**] 4:48 pm impression: mild vascular engorgement. no frank edema. small pleural effusion most likely bilateral. questionable nodular opacity in the right lower hemithorax may be a pulmonary nodule or nipple, repeated examination with nipple marking is recommended. extensive mediastinal widening with right tracheal deviation due to known goiter containing areas of calcification. the study and the report were reviewed by the staff radiologist. . portable tte (complete) done [**2161-8-3**] at 10:34:45 am final impression: left ventrivcular cavity enlargement with regional and global systolic dysfunction c/w multivessel cad. at least moderate mitral regurgitation. pulmonary artery systolic hypertension. brief hospital course: the patient is a [**age over 90 **] yo man who presented to osh for with chest pain, sob and fatigue who was found to be in v-tach with hypotension and was shocked twice, then transferred to [**hospital1 18**]. . # rhythm: it was felt that the patient's initial wide complex rhythm was ventricular tachycardia. on arrival to [**hospital1 18**], the patient was sable with a lbbb. he was maintained on his home medications with the exception of digoxin. while the etiology his initial tachycardia was unclear, scar related [**name (ni) 102121**] was considered the most probable given his history of mi. during his hospital course, the patient was mostly in sinus rhythm but did have one episode of asymptomatic v-tach 24 hours after admission. this lasted for approximately 16 beats and was self resolving. the patient was seen by the electrophysiology service who recommended permanently discontinuing digoxin in order to avoid it's proarrhythmic properties. the patient's dig level at the time of discharge was 0.6. he should follow-up with his outpatient cardiologist, dr. [**first name (stitle) **] [**name (stitle) **], the in next 2 weeks. . #a-fib: the patient had a history of slow a-fib with a history of paroxysmal a-fib. the patient was intermittently in a-fib during his hospital course. he was not on coumadin given his history on gib. he was continued on plavix. . # cad/ischemia: the patient had a history of mi in [**2129**] which was medically managed. troponins were elevated on admission (peak 0.71) and this was felt to be due to his cardioversion at the osh. the patient was started on aspirin while hospitalized but this was discontinued upon discharge given the patient's previously documented gi bleed/?adverse reaction to aspirin. . # pump/valves: the patient had a history of heart failure. echocardiogram was performed which demonstrated at least moderate mitral regurgitation and an ejection fraction of ~30%. chest x-ray was without evidence of volume overload. the patient was scheduled for a follow up appointment with his primary cardiologist. . # htn/hypotension: the patient has a history of hypotension but his blood pressures were low throughout most of his hospitalizations (sbp's in the 80's-100). the patient denied feeling symptomatic despite some orthostatic component to his hypotension. the patient was continued on his home bp medications and follow up was recommended. . # neuralgia: the patient was on neurontin for pain control. the patient denied pain during his hospital course. . # home safety: the patient was seen by physical therapy who recommended home pt as well as a home safety evaluation. medications on admission: digoxin 125 mcg daily neurontin 200 mg qhs carvedilol 12.5 mg daily plavix 75 mg daily furosemide 20 mg daily protonix 40 mg daily potassium chloride 20 meq daily quinapril 5 mg daily ferrous sulfate 325 mg daily discharge medications: 1. carvedilol 12.5 mg tablet sig: one (1) tablet po bid (2 times a day). 2. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 3. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 5. quinapril 5 mg tablet sig: one (1) tablet po daily (daily). 6. gabapentin 100 mg capsule sig: two (2) capsule po hs (at bedtime). 7. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po once a day. 8. potassium chloride 10 meq tablet sustained release sig: two (2) tablet sustained release po once a day. discharge disposition: home with service facility: caregroup home care discharge diagnosis: primary diagnosis: ventricular tachycardia low ef moderate/severe mitral valve regurgitation discharge condition: the patient was hemodynamically stable, afebrile and without pain at the time of discharge. discharge instructions: you were admitted for evlauation of shortness of breath and fatigue. it was felt that your symptoms were due to an irregular heart beat which resolved with an electric shock to your heart. beacause of this heart rhythm, you are at high risk for fainting and we recommend, for your safety as well as the safety of others, that you do not drive. . we have have stopped your use of digoxin and you should not take this medication at home. you should continue to take all of your other medications as previously directed. . please follow up with your cardiologist, dr. [**last name (stitle) **]. we have scheduled an appointment for [**8-18**] at 2:30pm. . during your admission, you were seen by physical therapy and they have recommended home physical therapy follow-up. this will be arranged for you. . please call your doctor or seek medical attention if you develop a return of your symptoms (fatigue. chest discomfort) or if you develop new symptoms of chest pain, nausea, vomiting, lightheadedness, changes in vision, muscle weakness or any other symptom of concern. followup instructions: please follow up with dr. [**first name (stitle) **] [**name (stitle) **] date: [**8-18**] time: 2:30 pm phone #: ([**telephone/fax (1) 97348**] completed by:[**2161-8-4**]",1
147,"admission date: [**2140-5-23**] discharge date: [**2140-5-30**] date of birth: [**2091-2-23**] sex: f service: medicine allergies: patient recorded as having no known allergies to drugs attending:[**first name3 (lf) 759**] chief complaint: shortness of breath, hypoglycemia major surgical or invasive procedure: s/p laryngoscope history of present illness: cc:[**cc contact info 100379**] present illness: ms. [**known lastname 100380**] is a 49 year old female with history of hcv, obesity, and esophageal cancer who presents after a family member found her unconscious, and noted a fingerstick blood glucose [**location (un) 1131**] of 40 mg%. the patient in er received glucagon, glucose, and iv hydration. fbs subsequently normalized in field and transported to er for further management. the patient reports taking her usual ""70 mg"" (?units) of insluin qd, although her oral intake has been diminshed of late secondary to esophageal pain. she has felt ""odd"" for approximately 1-2 weeks, noting mild diaphoresis during day, ""it might be my sugars..."" in er fbs 53 mg%, noted to be tranisently hypoxic with spo2=76%. this episode prompted concern for pe, and cta was attempted. ~60 ml iv contrast dye extravasated into the patient's arm, and a ct noncontrast of the chest was performed. no data regarding the neck / glottis area was obtained. past medical history: pmh: esophageal cancer dx [**2138**] (t2n0) supraglottic, treated with surgical resection and external beam radiation therapy. no chemotherapy was advised given risks of toxicity and comorbid conditions. peg tube placed [**11-28**], replaced [**12-30**] for nutritional support morbid obesity, unable to ambulate without wheelchair hepatitis c history of ivda (heroin). last use unknown, remains on methadone osteoarthritis of knees ulnar europathy dm2 on insulin pud / gerd social history: social history (based from chart records): etoh: drinks socially. smoking: 30 p-y hx; now smokes about 4 cigarettes/day. drug use: the patient is an iv heroin abuser who was on methadone for the 2 years prior to last month's hospitalization. the patient is on disability due to her obesity. she is a past victim of domestic violence. she has 4 children and lives with her son, who she reports dose not help out much. family history: one of the patient??????s aunts died of an unknown ca. the patient??????s mother died of an mi, and she states that her father died of ??????diabetes.?????? her two sons have schizophrenia. physical exam: vs: t98.2, bp 101/81, p80, r20, spo2 99% ra. fbs 101 gen: obese female in no distress. pleasant and conversant. clear sleep apnea with coarse, loud ""snoring."" cv: s1 s2 with no mrg. lungs: distant lung sounds difficult to auscultate secondary to body habitus. no wheezes. abd: overweight, nt/nd, normal bowel sounds. well-healed peg insertion site. ext: no edema. pertinent results: labs: 15.4 > 14.3/44.5 < 224 141 | 4.3 | 97 | 30 | 17 | 1.3 < 78 alt 14, ast 46, ldh 526, alkp 89, tbili 1.0, alb 3.5 lactate 2.4 [**2140-5-23**] 08:50am %hba1c-4.8# [hgb]-done [a1c]-done . urine tox positive for cocaine, opiates, and methadone serum tox negative . [**2140-5-23**] 10:24pm urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-sm urobilngn-1 ph-5.0 leuk-tr [**2140-5-23**] 10:24pm urine rbc-21-50* wbc-[**11-13**]* bacteria-many yeast-none epi-21-50 . ct chest non-contrast: patchy opacity in the left lower lobe most likely represent early infectious process. . ct neck non-contrast: no definite evidence of pathologic adenopathy. some distortion of intrinsic larynx. this can be evaluated with direct observation. no definite evidence of subglottic extension. . cxr: 1) slight improvement in left basilar opacity. 2) right base atelectasis. . left lower extremity doppler: no evidence of deep vein thrombosis within the common femoral or superficial femoral veins. the popliteal vein demonstrates normal color flow; however, secondary to body habitus, a waveform could not be obtained. as flow proximally to this vessel is normal, if a thrombus exists in the popliteal vein, it is nonocclusive. . brief hospital course: 1. endo -49 year old female with esophageal cancer s/p resection and radiation therapy admitted with hypoglycemia secondary to poor po intake. patient unsure of insulin regimen, but last discharge [**12-30**] was 80 u [**hospital1 **] of (70/30) mix. standing insulin regimen was held. blood sugars were relatively well contolled on [**name (ni) **] alone. pt had elevated bs in setting of high dose steroids, but normalized after discontinuation of steroids and didn't require sliding scale insulin. pt's hga1c is 4.8. pt was instructed to check [**hospital1 **] bs at home and to treat with sliding scale as needed. standing dose of insulin was discontinued. . 2. epiglottitis/supraglottitis: a few days into hospital course, pt was noted to be strigorous and short of breath, while maintaining o2 sats of mid 90s. pt was seen by ent who was consulted to perform a laryngoscope to look for a structural etiology of aspiration. at this point, ent noted a significantly compromised airway. pt's baseline 50% narrowed airway was decreased to 33% secondary to epiglotitis/supraglottisi. pt was also noted to be somnolent. abg was performed which showed acute respiratory acidosis secondary to co2 retention (7.26/78/73). pt was transferred to the unit for close respiratory monitoring. she was started on high dose steroids and iv unasyn with significant decrease in supraglottis on serial scopes. abg normalized. mental status and respiratory status normalized. after a few days in the [**name (ni) 153**], pt was transferred back to the floor where she continued to have q2h o2 sat checks while her steroids were tapered to off. pt's respiratory status remained stable. pt will be followed up by her ent doctor within one week of discharge. pt received around 5 days of unasyn and is to complete a 14 day course of augmentin for treatment of epiglottitis/supraglottitis. . 3. aspiration - she is clearly aspirating, noting that she always coughs after drinking water. at this visit, the patient took a sip of water and demonstrated aspiration, likely with abnormal swallowing secondary to pain and surgical procedure / radiation. pt was evaluated by speech and swallow who performed a video swallow and recommeded nectar thick liquids, ground solids, meds crushed in puree. pt was put on aspiration precautions. . 4. osa: pt may have underlying osa in setting of morbid obesity. pt should obtain a sleep study as an outpatient. . 5. id - pt had evidence of aspiration pna in lll. pt was started on levo/flagyl, which were discontinued after initiation of unasyn. pt remained afebrile with minimal symptoms. serial cxrs showed improvement in lll opacity. pt also has uti, which was adequately treated with antibiotics. blood and urine cultures were negative. . 6. formication: pt describes a several month history of feeling hair falling on her skin. she describes the sensation as tingling. ddx includes cocaine (positive tox screen), other drug use (i.e. heroin), pschiatric disorder. none of her current medications are likely to cause such an adverse reaction. . 7. polysubstance use: pt was continued on home dose of methadone for hx of heroin use. she was seen by substance abuse social work consult. . 8. le swelling: pt was noted to have asymmetric left foot swelling associated with pain. pt reported a prior hx of dvt. le ultrasound was negative for dvt. . 9. loose stools: pt had negative cdiff x2. medications on admission: methadone 90mg qd insulin 70/30 70-30 80u [**hospital1 **] hydromorphone hcl 4 mg tablet sig: 1-2 tablets po q3-4hrs as needed for 4 days. (prescribed [**2139-12-26**]) protonix 40mg po qd discharge medications: 1. augmentin 875-125 mg tablet sig: one (1) tablet po twice a day for 14 days. disp:*28 tablet(s)* refills:*0* 2. methadone hcl 40 mg tablet, soluble sig: two (2) tablet, soluble po daily (daily). 3. methadone 10 mg/ml concentrate sig: one (1) po once a day. 4. oxycodone-acetaminophen 5-500 mg capsule sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. disp:*30 tablet(s)* refills:*0* 5. lorazepam 1 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 6. insulin lispro (human) 100 unit/ml cartridge sig: one (1) subcutaneous twice a day: in am and before dinner. 7. lancets misc sig: one (1) miscell. twice a day. disp:*60 60* refills:*2* discharge disposition: home with service facility: [**location (un) 86**] vna discharge diagnosis: epiglottitis/supraglottitis aspiration pneumonia hypoglycemia osa discharge condition: stable o2 saturations, breathing comfortably discharge instructions: if you develop fevers, chills, difficulty breathing, lightheadedness, dizziness, or any other concerning symptoms call your doctor or return to the emergency room immediately. followup instructions: follow up with dr.[**first name8 (namepattern2) **] [**last name (namepattern1) **], m.d. on [**6-8**] at 3:45pm.(call ([**telephone/fax (1) 6213**] to reschedule) . follow up with your primary care doctor dr. [**last name (stitle) 100381**] [**name (stitle) **] have your primary care doctor follow up on your blood sugars. we are stopping your insulin for now because your blood sugars have been under good control. . provider [**name9 (pre) **] [**last name (namepattern4) 2424**], md where: lm [**hospital unit name 7129**] center phone:[**telephone/fax (1) 2422**] date/time:[**2140-7-19**] 11:00",1
148,"admission date: [**2168-10-9**] discharge date: [**2168-10-13**] service: neurology allergies: colchicine / omeprazole / doxazosin / cipro i.v. / lipitor attending:[**last name (namepattern1) 1838**] chief complaint: headaches major surgical or invasive procedure: arterial line [**2168-10-9**] history of present illness: [**age over 90 **]y f with history notable for bilateral sdh s/p evac here at [**hospital1 18**] in [**2166**] as well as chronic, recurrent non-migrainous headaches, hypertension, and remote h/o migraine ha. who returns to our ed for the second time in two weeks for persistent/recurrent headache. i saw ms. [**known lastname 1968**] a little over a week ago in our ed ([**9-30**], friday) for her headache, which was similar to now and similar to several previous presentations. at that time, her headache had started one day after she started a new medication (amlodipine at a low dose). it had been going on for several days at that time, with only partial relief from fioricet and motrin, and a one-day spell of relief during a brief stay at [**hospital1 **] where she got reglan. there, nchct was unremarakable (both the report and the images, which i reviewed at that time) and a carotid doppler u/s of the carotids study was reportedly without e/o stenosis. we recommended f/u with her outpatient neurologist (dr. [**last name (stitle) **] has been following her since [**2166**]), and stopping the medication that may have triggered the ha (amlodipine) and follow up with her pcp [**name9 (pre) 2678**] to try a different anti-hypertensive [**doctor last name 360**] because her bp was 170/x at that time (despite the amlodipine). also recommended giving reglan, which had worked at [**hospital1 **]. pt tells me now that the headache went away for a day or less after the reglan she got here last week, but returned, again present every day at the same intensity or worse, no full relief from the aforementioned analgesics. stopping the amlodipine did not seem to have any effect on the ha. she followed up with dr. [**last name (stitle) **] this past monday ([**10-3**]), and he recommended trying verapamil extended-release 120mg daily for the bp and headaches in lieu of the amlodipine. she checked with her cardiologist, who said this was ok, and has been taking it for a few days now, but no relief from the [**last name (lf) **], [**first name3 (lf) **] she returned to the ed. here, her bp has ranged from 190s-250s systolic over 70s to 110s diastolic, and did not respond well to labetalol or hydralazine. the ed staff planned to admit to medicine icu ([**hospital unit name 153**]) for blood pressure control, but dr. [**last name (stitle) **] noticed that she was in the ed and visited and recommended that we could admit to our neuro-icu service since we are familiar with the patient and he is attending on the inpatient service this week. on my interview with her, she gave the details as listed above and says that nothing else has changed since our last encounter except that she is frustrated that the headache won't stay away. her daughter is concerned about the situation and there is some disagreement between her and the patient about the desired amount of diagnosis and treatment -- patient requests dnr/dni and does not want, e.g., cta or potential coil/clipping if she were found to have an aneurysm. she also takes off the bp cuff and refuses bp cuff measurments because she says it hurts her arm. she says she will allow a-line placement and iv managment of her bp. ros: negative except as above and as noted in previous ed consult note from [**9-30**] (no changes). past medical history: 1. remote h/o migraine has 2. bilateral sdh/hygromas [**4-/2166**] s/p evacuation and resolution; no neurologic sequelae except intermittent vertex has since that time, including this week. 3. h/o dm2, but this was apparently related to hydrocortisone use for her low back pain; her daughter explained that the patient stopped requiring any diabetes medications since discontinuing the hydrocortisone (and also lost 10-20lbs recently). 4. obesity 5. hypertension on [**last name (un) **], bb, and recently started on ccb (the day before the headache started). 6. chronic anemia, on feso4 (not taking) and epo injections (taking). 7. depression, on ssri 8. hyperlipidemia, no longer taking statin (adverse reaction to atorvastatin) 9. h/o gout 10. h/o melanoma 11. h/o ""spastic colon"" on mesalamine 12. remote surgical history of gastrectomy, t&a, hysterectomy, ""bladder lift"" 13. hypothyroidism 14. low back pain, chronic - takes tramadol (""my favorite""), formerly experienced better relief with hydrocortisone. 15. chronic renal failure, which her daughter says was [**2-10**] adverse reaction to prilosec. recently discontinued from furosemide by nephrologist due to uremia (per dtr.). - denies any h/o stroke, tia, mi, cad social history: no tobacco, etoh family history: family history is notable for many relatives esp. women living into 90s or 100+ years old. physical exam: admission physical exam: vital signs: t 98.6f hr 86, reg bp 196/119 --> 180-190 / 74 on my exam rr 24 --> teens on my exam sao2 100% general: lying in ed stretcher in trauma bay, daughter sitting next to her. smiling, remembers me from last week. appears comfortable, in nad. heent: normocephalic and atraumatic. surgical pupils bilaterally. no scleral icterus. mucous membranes are moist. no lesions noted in oropharynx. neck: supple, with minimally restricted range of motion; no rigidity. no bruits. no lymphadenopathy. pulmonary: lungs cta. non-labored. cardiac: rrr, normal s1/s2, soft systolic murmur @usb. abdomen: obese. soft, non-tender, and non-distended. extremities: obese. warm and well-perfused, no clubbing, cyanosis, or edema. 2+ radial, dp pulses bilaterally. c/o pain at both ue from bp cuff. ***************** neurologic examination: mental status exam: oriented to person, [**2168**], [**month (only) 359**], location, reason for treatment. some difficulty relating some historical details, as before; daughter fills in the rest. attentive, able [**doctor last name 1841**] forward and backward. speech was not dysarthric. repetition was intact. language is fluent with intact repetition and comprehension, normal prosody, and normal affect. there were no paraphasic errors. naming is intact to both high and low frequency objects (watch, band, pen, stethescope). anterograde memory excellent [**3-10**] --> [**3-10**] as before. no evidence of apraxia or neglect or ideomotor apraxia; the patient was able to reproduce and recognize brushing hair with right hand; used fingers/hand to represent toothbrush on brushing teeth with left hand. calculation intact (answers seven quarters in $1.75 and $0.32). left-right confusion as before; touched her left ear with her left hand instead of r ear with left hand. -cranial nerves: i: olfaction not tested. ii: surgical, non-reactive pupils bilaterally (old cataracts procedure). visual fields are full. disc sharp and vessels normal on the right; cannot visualize left fundus at this time. iii, iv, vi: eoms full and conjugate with no nystagmus. no saccadic intrusion during smooth pursuits. normal saccades. v: facial sensation intact and subjectively symmetric to light touch v1-v2-v3. vii: no ptosis, no flattening of either nasolabial fold. brow elevation is symmetric. eye closure is strong and symmetric. normal, symmetric facial elevation with smile. viii: hearing intact and subjectively equal to finger-rub bilaterally; worse hearing loss on left vs. extinguishes on left. ix, x: palate elevates symmetrically with phonation. [**doctor first name 81**]: [**5-12**] equal strength in trapezii bilaterally. xii: tongue protrusion is midline. -motor: no pronator drift, and no parietal up-drift bilaterally. mild resting tremor left>right, less pronounced than 1wk ago. no asterixis. normal muscle bulk and tone, no flaccidity. mild hypertonicity of rle. delt bic tri we ff fe io | ip q ham ta [**last name (un) 938**] gastroc l 5 5 5 5 5 5 5 5 5 5 5 5 5 r 5 5 5 5 5 5 5 4* 5 4* 5 5 5 * pain-limited (causes pain in right lower back) -sensory: no gross deficits to light touch, pinprick, cold sensation sensation in either upper or distal lower extremity. joint position sense minimally impaired in both both great toes and subtly in rue (missed nose initially; may have been [**2-10**] compression from bp cuff which i just deflated before test). - cortical sensory testing: no agraphesthesia or astereoagnosia. no extinction. -reflex examination (left; right): biceps (++;++) triceps (++;++) brachioradialis (++;++) quadriceps / patellar (++;++) gastroc-soleus / achilles (0;0) plantar response was mute bilaterally. -coordination: finger-nose-finger testing with no dysmetria or intention tremor, mild tremor. heel-knee-shin testing with no dysmetria. no dysdiadochokinesia. -gait: deferred, given the labile bp and pt preference ______________________________________________________________ discharge examination: no change from initial examination except for variable orientation: oriented to name and place but not month, year, or hospital name. pertinent results: admission labs: [**2168-10-9**] 08:30am blood wbc-5.8 rbc-3.96* hgb-11.8* hct-33.4* mcv-84 mch-29.8 mchc-35.3* rdw-15.1 plt ct-173 [**2168-10-9**] 08:30am blood neuts-60.1 lymphs-26.1 monos-4.7 eos-8.6* baso-0.6 [**2168-10-10**] 03:59am blood pt-11.5 ptt-21.7* inr(pt)-1.0 [**2168-10-9**] 08:30am blood glucose-138* urean-34* creat-1.4* na-139 k-5.2* cl-109* hco3-20* angap-15 [**2168-10-10**] 03:59am blood alt-12 ast-14 ck(cpk)-288* alkphos-112* totbili-0.3 [**2168-10-10**] 03:59am blood albumin-4.2 calcium-10.2 phos-2.6* mg-2.0 [**2168-10-10**] 03:59am blood tsh-4.9* discharge labs: na 139, k 4.5, cl 107, hco3 20, bun 35, cr 2.2 wbc 5.2, hgb 10.3, plt 139 imaging: ct head [**2168-10-9**]: impression: 1. post-sdh evacuation changes in the bilateral frontal calvarium. 2. no intracranial hemorrhage. cxr [**2168-10-9**]: heart size is normal. mediastinum is normal. lungs are essentially clear. there is no pleural effusion or pneumothorax. elevation of left hemidiaphragm is unchanged. brief hospital course: [**known firstname 2127**] [**known lastname 1968**] is a [**age over 90 **] yo woman with pmhx of bilateral sdh/hygromas in [**2166**] s/p evacuation and resolution, dm, htn, hl and hypothyroidism who presented with ha x2 weeks and hypertensive urgency, thought to be causing the headaches. . # neurologic: patient was initially on a nicardipine gtt, but this was able to be stopped on [**10-10**]. we initially continued her on verapamil sr 120mg that was started prior to her admission as well as her home valsartan. we increased her toprol xl dose and restarted her on lasix 20mg to help control her bp. she refused bp checks with a cuff because they were ""too painful"". therefore, we kept her in the icu to have her bp monitored with an a-line. she was started on clonidine as well for blood pressure management and was transferred from the icu to the floor. she developed orthostasis the next day, but this resolved quickly with intravenous fluids and the holding of her blood pressure medications. we decided on a final regimen of metoprolol succinate (50mg xl), clonidine (0.1 [**hospital1 **]), and valsartan (home dose, 320 mg daily) for her blood pressure management. # cardiovascular: she did not have any events on telemetry while here. her hr remained stable in the 70's after we increased her toprol xl dose from 25->50mg qd. we restarted her lasix after discussing this with her outpatient nephrologist (who was previously prescribing it). this helped to control her bp and her ha's. # infectious disease: pt had a u/a with wbcs and leukocytes but no bacteria, so we waited to see if the ucx grew anything before considering abx as she was not symptomatic. # hematology/oncology: patient has known mild anemia, is on epo as an outpatient. her hct remained stable throughout this hospitalization. # endocrine: we continued patient's l-thyroxine, however her tsh was mildly elevated at 4.9. her free t4 was 1.2 (normal). # nephrology/urologic: pt has known chronic kidney disease, which began with prilosec treatment and per daughter plateaued and improved after withdrawal of this medication. we monitred her potassium and bun/cr, which remained increased after starting furosemide, likely also with a contribution of volume depletion. we stopped her furosemide and will not restart this medication at this time. # code/contact: dnr/[**name2 (ni) 835**] requested by pt; daughter [**telephone/fax (1) 99907**] transitional care issues: [ ] she will need her bp monitored and her bun + cr monitored to ensure that they stay within her baseline ranges. [ ] please recheck her electrolytes to monitor her potassium and creatinine. [ ] she will be going to rehab for a short course for physical therapy to improve her gait stability. medications on admission: 1. verapamil sr 120mg daily (started earlier this week) 2. procrit 3. fiorinal 50/325/100 - prn for headaches (takes < 1/day) 4. motrin ?600mg otc - prn for headaches (takes 1+ per day q8+h) 5. tramodal 50mg prn for back pain (takes < 1/day) 6. valsartan (diovan) for htn 320mg daily 7. sertraline (zoloft) for mood 25mg daily 8. ondansetron (zofran) 4mg prn for nausea (took a few this wk) 9. metoprolol-succinate (xr) 25mg daily (?for htn) 10. mesalamine 400mg q8h for gi discomforts 11. pantoprazole (protonix) 40mg daily 12. folic acid 1mg daily 13. mvi daily 14. vit d qsun 15. levothyroxine 100mcg daily * [ amlodipine 5mg daily --> started this past monday, [**2168-9-28**] ] * [ furosemide 40mg qod discontinued 2wks ago by nephrologist due to uremia, per daughter ] * [ gemfibrozil 400mg tid & glipizide 5mg daily discontinued recently by pcp, [**name10 (nameis) **] [**name11 (nameis) 8472**] [**name initial (nameis) **] while ago due to improved blood sugar and a1c down to 6% after stopping hydrocortisone for back pains ] discharge medications: 1. tramadol 50 mg tablet sig: one (1) tablet po twice a day as needed for low back pain (home med). 2. valsartan 160 mg tablet sig: two (2) tablet po daily (daily) as needed for hypertension (home med/dose). 3. sertraline 25 mg tablet sig: one (1) tablet po daily (daily) as needed for mood (home med). 4. mesalamine 250 mg capsule, extended release sig: four (4) capsule, extended release po tid (3 times a day) as needed for gi discomfort (home med). 5. folic acid 1 mg tablet sig: one (1) tablet po daily (daily) as needed for home med. 6. levothyroxine 50 mcg tablet sig: two (2) tablet po daily (daily) as needed for hypothyroidism (home med/dose). 7. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po 1x/week ([**doctor first name **]). 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours) as needed for gerd. 9. ondansetron 4 mg iv q8h:prn nausea (takes 4mg odt at home prn) 10. multivitamin tablet sig: one (1) tablet po daily (daily) as needed for home med. 11. clonidine 0.1 mg tablet extended release 12 hr sig: one (1) tablet extended release 12 hr po twice a day: for management of blood pressure. 12. metoprolol succinate 50 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day: for control of blood pressure. discharge disposition: extended care facility: [**hospital3 15644**] long term care - [**location (un) 47**] discharge diagnosis: primary: hypertensive urgency secondary: chronic headaches, history of subdural hematomas discharge condition: mental status: confused - sometimes. level of consciousness: lethargic but arousable. activity status: ambulatory - requires assistance or aid (walker or cane). neurologic: oriented to name and place but not hospital name or month/year. otherwise no focal deficits. discharge instructions: dear ms. [**known lastname 1968**], you were seen in the hospital because of headaches and high blood pressure. while here we controlled your blood pressure, initially on intravenous medications, and then on oral medications. your blood pressure improved, and when this happened, your headaches also improved. we made the following changes to your medications: 1. we would like you to continue taking valsartan 320 mg by mouth daily for control of your blood pressure. 2. we would like you to take a higher dose of metoprolol. the new dose will be metoprolol succinate (extended-release) 50 mg by mouth daily. 3. we would like you to take a new blood pressure medication called clonidine 0.1 mg by mouth twice daily. this is a very strong blood pressure medication. it is very important to adhere to the twice daily scheduling of this medication as not taking this medication can cause a quick rise in your blood pressure. 4. please stop taking the medication furosemide. 5. please stop taking the medication verapamil. please continue to take your other medications as previously prescribed. if you experience any of the below listed danger signs, please contact your doctor or go to the nearest emergency room. it was a pleasure taking care of you on this hospitalization. followup instructions: department: neurology when: wednesday [**2168-11-9**] at 2:00 pm with: [**first name8 (namepattern2) **] [**last name (namepattern1) 640**] [**last name (namepattern4) 3445**], md [**telephone/fax (1) 2574**] building: sc [**hospital ward name 23**] clinical ctr [**location (un) 858**] campus: east best parking: [**hospital ward name 23**] garage",1
149,"admission date: [**2101-4-14**] discharge date: [**2101-4-22**] service: micu chief complaint: abdominal pain, vomiting and diarrhea. history of present illness: a 78-year-old woman with a history of multiple psychiatric admissions for bipolar disorder as well as hypertension, chronic obstructive pulmonary disease, diverticulosis, barrett's esophagus who was recently on ciprofloxacin for a urinary tract infection for the past three days and was found on the floor by her husband covered in brown feces and vomit. she was noted to then be vomiting dark brown material. she reported abdominal pain that was right-sided, crampy and nonradiating on the night prior to admission also associated with vomiting and diarrhea. she also noted fatigue. the husband called 911 and the patient was seen by emergency medical services at the scene with vital signs: heart rate 98, blood pressure 138/palp, respiratory rate 16, oxygen saturation 96% on four liters nasal cannula. on arrival to the emergency department, her vital signs were 150/82, 92, 18, 100% on room air with a temperature of 96.2. she vomited a small amount of coffee ground material times two. an ng tube was placed to suction and the patient subsequently had bright red blood per rectum. two peripheral iv's were placed. labs were notable for a wbc count of 26.5, hematocrit of 47 and a bun/creatinine of 35/1.4. she received two liters of normal saline, levofloxacin and flagyl as well. ct of the abdomen was performed which demonstrated diffuse colonic thickening. surgery was consulted who considered ischemic versus infectious colitis. past medical history: 1. hypertension. 2. chronic obstructive pulmonary disease on two liters nasal cannula home oxygen. 3. bipolar disorder. 4. barrett's esophagus. 5. osteoporosis. 6. macular degeneration. 7. status post cholecystectomy. 8. history of thrush. 9. multiple psychiatric admissions for bipolar disorder, most recent [**3-1**] to [**2101-3-31**]. 10. urinary tract infections. 11. echocardiogram [**11/2099**] with ejection fraction of 65-70%. 12. constipation and abdominal pain of long-standing duration. 13. diverticulosis. allergies: prednisone, sulfa, calcium channel blockers, keflex, benadryl and beta blockers. medications: 1. clonidine patch 0.2 q. week. 2. cozaar 50 mg p.o. b.i.d. 3. albuterol p.r.n. 4. atrovent two puffs q.i.d. 5. flovent 110 mcg two puffs b.i.d. 6. prilosec 20 mg p.o. b.i.d. 7. seroquel 200 mg p.o. q. hs. 8. lasix 40 mg p.o. q. day. 9. lactulose p.r.n. 10. aspirin 81 mg p.o. q.o.d. 11. cipro 250 mg p.o. b.i.d. 12. depakote 500 mg p.o. q. hs. 13. hydralazine 25 mg p.o. b.i.d. 14. k-dur 10 meq p.o. q. day. 15. dulcolax p.r.n. 16. two liters nasal cannula oxygen. 17. os-cal. 18. milk of magnesia. 19. nitro patch ? family history: unknown. social history: the patient is a former heavy tobacco smoker who quit 13 years ago. no history of alcohol abuse. she lives alone. she is separated from her husband who does provide some support as well as her daughter. [**name (ni) **] history of drugs or herbal supplement use. physical examination: 101.2, 128/47, 107, 28, 90% on room air. general: this is an elderly woman lying on her left side with an ng tube in place. declining to lie flat for an examination but otherwise in no acute distress. heent: right pupil surgical. left pupil 2 mm, nonreactive. no scleral icterus. mucus membranes moist. no lesion. neck supple. no lymphadenopathy. no bruits. jugular venous pressure could not been seen. cor regular rate and rhythm. normal s1, s2. grade [**2-10**] holosystolic murmur at the right upper sternal border without radiation. no s3 or s4 appreciated. lungs: diffusely decreased breath sounds bilaterally. no crackles, wheezes or rhonchi. abdomen: protuberant, distended, no obvious surgical scars. examination limited by patient refusing to lie flat. positive high pitched bowel sounds. soft, diffusely tender, no rebound or guarding. extremities warm, well perfused, 2+ dorsalis pedis pulses bilaterally. rectal: guaiac positive. skin warm, dry, no rashes. laboratory: wbc 26.5, hematocrit 47, platelet count 324,000. 84 bands, 3l4. bun/creatinine 35/1.4. anion gap 15. urine tox negative. serum tox negative. abg 7.3/49/65. radiology: kub without volvulus or intestinal obstruction. probable distended bladder. chest x-ray: no free air. electrocardiogram: normal sinus rhythm, normal axis, intervals, no ectopy. left atrial enlargement, no q-waves. j-point elevation in v1 and v2. one millimeter st depression in 2, 3 and f. positive left ventricular hypertrophy. when compared to ekg in [**2100-2-5**], the st depressions were new. hospital course: 1. colitis: while in the micu, the patient had spiked a fever to 101.2 and had significant bandemia. she had an anion gap of 15 with a lactate of 4.1. she continued to note abdominal pain with diarrhea initially. was being treated with vancomycin, levofloxacin and flagyl and received aggressive intravenous fluid hydration. clostridium difficile and stool cultures were sent and were all negative. it was unclear whether or not the patient had infectious colitis versus ischemic colitis with super infection from transmutation of flora. gastroenterology was consulted who could not provide a definitive diagnosis either. due to the patient's cardiac issues the patient was not sent for scope. over the course of several days, the patient's fever went down and her white count decreased. she was taken off the vancomycin and maintained on levofloxacin and flagyl. she will continue a 14 day course of these medications. she should have an outpatient colonoscopy performed by gastroenterology. no source of upper gi bleeding was noted. it is possible that this could have been from her lower gi sources. outpatient workup is indicated. she was tolerating a regular diet at the time of discharge. 2. atrial fibrillation: the patient's blood pressure medications were held on admission due to concern over gastrointestinal bleeding. on the day after admission the patient was noted to be atrial fibrillation with a rapid ventricular response. she was given lopressor iv push that resulted in a six second pause. given the patient's reported history to beta blockers and calcium channel blockers, electrophysiology was consulted, especially with the concern of av nodal disease. the patient was started on a verapamil drip. she was then changed to p.o. verapamil 80 mg p.o. t.i.d. the patient fluctuated between atrial fibrillation and normal sinus rhythm with a well controlled rate. the verapamil was discontinued on hospital day three. the patient was transferred to the floor for additional workup of her gi issues. on the night she was sent to the floor the patient again had atrial fibrillation with a rapid ventricular response with a heart rate in the 150's to 170's with a blood pressure in the 70's systolic. she was brought back to the micu and placed on a verapamil drip with good control of her blood pressure. she was then changed to verapamil 40 mg p.o. t.i.d. with good control of her ventricular response. she went back and forth between atrial fibrillation and normal sinus rhythm. decision was made not to anticoagulate given her gastrointestinal issues and recent gi bleed. electrophysiology continued to consult and directed that if her rate was not well controlled with the p.o. verapamil that additional nodal blockade with amiodarone or other agents may be necessary and might require a pacemaker. they were not willing to do this procedure at this time due to her stable condition and gi issues. 3. chronic obstructive pulmonary disease: this patient was maintained on her albuterol, atrovent and flovent inhalers. she did not experience any copd exacerbations. she was maintained on her home oxygen requirement and was discharged on one liter of home oxygen. 4. hypertension: the patient has likely poorly controlled hypertension as an outpatient. she had her antihypertensives held and then restarted. the patient was on cozaar as an outpatient and was placed on captopril as an inpatient. she did not have any adverse reactions to this medication. she was maintained on low dose to keep her blood pressure systolic greater than 120 give a question of ischemic colitis. she was discharged on verapamil and lisinopril. 5. bipolar disorder: the patient was initially seen with depakote 500 mg p.o. q. hs. and seroquel 200 mg p.o. q. hs. the patient was seen to be very somnolent during her admission in the micu on this dose of seroquel. the dose was decreased to 100 mg p.o. q. hs. and the patient was more alert. she will be discharged on this dose with follow up with her psychiatrist. condition at discharge: stable. discharge status: patient will be discharged to rehabilitation. she will follow up with psychiatry, gastroenterology and cardiology. discharge diagnoses: 1. colitis, ischemic versus infectious. 2. atrial fibrillation complicated by rapid ventricular response and hypotension. 3. lower gastrointestinal bleed. 4. upper gastrointestinal bleed. 5. chronic obstructive pulmonary disease on home oxygen. 6. bipolar disorder. discharge medications: 1. tylenol 325 mg to 650 mg p.o. q. 4h. p.r.n. 2. atrovent two puffs q.i.d. 3. albuterol two puffs q.i.d. p.r.n. 4. depakote 500 mg p.o. q. hs. 5. flagyl 500 mg p.o. t.i.d. for five days until [**2101-4-27**]. 6. simethicone 80 tabs 1.5 tabs q.i.d. p.r.n. 7. levofloxacin 250 mg p.o. q. day for five days until [**2101-4-27**]. 8. seroquel 100 mg p.o. q. hs. 9. prevacid 30 mg p.o. q. day. 10. verapamil 40 mg p.o. t.i.d. 11. lisinopril 10 mg p.o. q. day. 11. calcium and vitamin d. 12. aspirin 81 q.o.d. held due to lower gi bleed. [**first name4 (namepattern1) **] [**last name (namepattern1) **], m.d. [**md number(1) 3795**] dictated by:[**name8 (md) 17420**] medquist36 d: [**2101-4-22**] 12:37 t: [**2101-4-22**] 12:23 job#: [**job number 101226**]",0
150,"admission date: [**2146-1-11**] discharge date: [**2146-1-18**] date of birth: [**2093-7-26**] sex: m service: age: 52. history of the present illness: this is a 52-year-old male patient with a known history of coronary artery disease, who is status post myocardial infarction followed by three-vessel coronary artery bypass graft in [**2126**]. past medical history: 1. hypertension. 2. diabetes mellitus. 3. hypercholesterolemia. the patient was admitted to the hospital with unstable angina. he has had recent increase in symptoms about a month prior to admission. on the day of admission to the hospital, the patient had significant increase in symptoms and was directed to the emergency department. he was admitted to the cardiology medicine service at that time. past medical history: 1. coronary artery disease, as previously stated. 2. hypertension, noninsulin dependent diabetes mellitus. 3. hypercholesterolemia, status post right rotator cuff surgery repair, status post right submandibular gland removal secondary to stone and erectile dysfunction. medications: 1. prinivil 10 mg p.o.q.d. 2. atenolol 10 mg p.o.q.d. 3. aspirin 325 mg p.o.q.d. 4. the patient also is enrolled in a study for hypercholesterolemia for which he is on unknown medication, as well as vitamin c and vitamin e. allergies: the patient has no known drug allergies. physical examination: physical examination on admission revealed the following: vital signs were within normal limits. heent: unremarkable. neck: supple. lungs: lungs were clear to auscultation, bilaterally. cardiovascular: examination revealed regular rate and rhythm with grade 2/6 systolic murmur. abdomen: obese and benign. extremities: unremarkable with palpable pulses. neurological: neurologically, he was alert and oriented. cranial nerves ii to xii grossly intact. laboratory data: laboratory values, upon admission to the hospital were all unremarkable. the patient's ekg revealed normal sinus rhythm with a right bundle branch block, no q-waves or st-wave abnormalities. the patient was admitted to the telemetry floor on the cardiology medicine service. the patient was taken to the cardiac catheterization laboratory on [**2146-1-12**]. cardiac catheterization revealed three-vessel coronary artery disease, occluded saphenous vein graft to the circumflex, lad, as well as a patent saphenous vein graft to the right coronary artery. he also was found to have mild left ventricular systolic dysfunction, as well as elevated left ventricular and diastolic pressure. cardiothoracic surgery consultation was obtained at that time. it was felt that the patient should be taken to the operating room for redo coronary artery bypass graft. on [**2146-1-13**], the patient was taken to the operating room, where he underwent redo coronary artery bypass graft times three; with lima to lad, saphenous vein to om2, saphenous vein to diagonal branch. (please see operative note for full details of surgical procedure) postoperatively, the patient was transported from the operating room to the cardiac surgery recovery unit with an intraaortic balloon pump in place. he was on levophed, milrinone, insulin and amiodarone drips. the patient was placed on iv pressonex drip for sedation due to a questionable adverse reaction in the operating room to propofol. on postoperative day #1, the patient had stabilized overnight and was slowly weaned off his vasoactive and inotropic drips. the intraaortic balloon pump was discontinued late in the day on postoperative day #1. he was weaned from the mechanical ventilator and ultimately extubated on that day as well. on postoperative day #2, the patient had remained hemodynamically stable. swan-ganz catheter was discontinued. the iv amiodarone was converted to oral. chest tubes were discontinued and he was transferred from the icu to the cardiothoracic telemetry floor. later in the day, on postoperative day #2, it was noted that the patient had an episode of atrial fibrillation. blood pressure was stable at that time and he was maintained on his amiodarone. over the next twenty-four hours the patient had a few more episodes of atrial fibrillation. he was started on lopressor and this was increased. he converted to normal sinus rhythm, early in the morning of [**month (only) 1096**] and he has remained in normal sinus rhythm since that time. the patient was begun on physical therapy and cardiac rehabilitation. he has progressed with increasing mobility. the epicardial pacing wires were discontinued on [**1-17**]. the patient was being diuresed and tolerating that well. he remained afebrile. he continued to progress from the cardiac rehabilitation standpoint. today, on postoperative day #5, [**2146-1-18**] the patient remained stable and is ready to be discharged home. condition on discharge: stable. temperature is 99.4, pulse 70, normal sinus rhythm. regular rate and rhythm 20: blood pressure 135/75. oxygen saturation is 95% on room air. most recent laboratory values are from [**2146-1-17**], which include a white blood cell count of 10.8, hematocrit of 23.4, platelet count 141,000, sodium 139, potassium 4.1, chloride 100, co2 30, bun 26, creatinine 0.9, glucose 146. prothrombin time 13.4. weight today, [**1-18**], is 125.6 kg, which is up from his preoperative weight of 117.8. neurologically, the patient is grossly intact with no apparent focal deficits. pulmonary examination is unremarkable. lungs were clear to auscultation bilaterally. coronary examination is regular rate and rhythm with no rubs nor murmurs. abdomen is obese, soft, and nontender with positive bowel sounds. sternum is stable. staples to the sternal incisions are intact. there is no erythema or drainage. there is a scant amount of serous drainage from his old chest-tube site. left flank incisions are clean, dry, and intact with no erythema. discharge medications: 1. lopressor 50 mg p.o.b.i.d. 2. lasix 20 mg p.o.b.i.d. times one week. 3. potassium chloride 20 meq p.o. b.i.d. times one week. 4. colace 100 mg p.o.b.i.d. 5. zantac 150 mg p.o.b.i.d. 6. enteric coated aspirin 325 mg p.o.q.d. 7. amiodarone 400 mg p.o.b.i.d. times five days, then 400 mg p.o.q.d. time two weeks, then 200 mg p.o.q.d. 8. ferrous sulfate 325 mg p.o.t.i.d. 9. percocet 5/325 one to two tablets p.o.q.4h.p.r.n.pain. 10. ibuprofen 400 mg p.o. q.6h.p.r.n.pain. follow-up care: the patient is to followup with dr. [**first name4 (namepattern1) **] [**last name (namepattern1) **] in one month for postoperative check. the patient is to followup with primary care physician, [**last name (namepattern4) **]. [**first name (stitle) **] [**name (stitle) 1395**] in two to three weeks. discharge diagnosis: coronary artery disease status post redo coronary artery bypass graft times three. discharge condition: stable. [**first name11 (name pattern1) 1112**] [**last name (namepattern1) **], m.d. [**md number(1) 3113**] dictated by:[**name8 (md) 964**] medquist36 d: [**2146-1-18**] 09:21 t: [**2146-1-18**] 09:30 job#: [**job number 103267**]",1
151,"admission date: [**2123-3-20**] discharge date: [**2123-3-21**] date of birth: [**2060-4-22**] sex: m service: medicine allergies: penicillins / morphine / lisinopril / sulfa (sulfonamide antibiotics) / pyramethamine attending:[**first name3 (lf) 3556**] chief complaint: pyrimethamine desensitization major surgical or invasive procedure: pyrimethamine desensitization history of present illness: dr. [**known firstname 449**] [**known lastname **] is a 62 yo male with history of recurrent retinal toxoplasmosis who presents for pyrimethamine desensitization. he was first diagnosed with ocular toxoplasmosis in [**2121-8-16**] by fundoscopic examination and toxoplasma seroconversion. he had no cat exposures, but had planted a garden with soil from the area dump, which he believes may have been contaminated with feral cat feces. he was treated initially with sulfadiazine and pyrimethamine, however, he developed rash and fever felt to be due to sulfadiazine, and his initial course of therapy was completed with pyrimethamine alone for approximately 6-8 weeks, with normalization of his vision. he had recurrance of ocular toxoplasmosis in [**month (only) 956**] and [**month (only) 116**] of [**2122**], again with normalization of his vision after treatment. this [**month (only) 404**], he had recurrence of visual symptoms in his right eye only. a repeat exam on [**2-22**] showed changes characteristic for active ocular toxoplasmosis. he was administered intravitreous clindamycin, and presented to [**hospital **] clinic for further management on [**2123-2-25**]. he was given clindamyacin and pyrimethamin for treatment. 2 days ago he developed angioedema of his lower lip, which resolved with benadryl and stopping the medication. he was rechallenged in the allergy clinic yesterday and again developed angioedema of the lower lip. he has not had any throat/tongue swelling or respiratory problems. [**name (ni) **] otherwise feels well. as directed, by dr. [**last name (stitle) **], he took prednisone 60mg po yesterday and today. past medical history: 1. diverticulitis status post left hemicolectomy with low anterior resection in [**2107**] by dr. [**last name (stitle) **]. this was complicated by incisional hernia status post repair in [**2113**]. 2. left fifth toe fracture [**2110**]. 3. hypertension. 4. hyperlipidemia. 5. pneumonia in [**2116**]. 6. back hemangioma excised in [**4-/2117**] by dr. [**last name (stitle) **]. 7. epidural inclusion cyst, excised by dr. [**last name (stitle) **] in 04/[**2117**]. 8. left subareolar mass in 06/[**2119**]. found to be gynecomastia and removed by dr. [**last name (stitle) 101862**]. 9. left eye vitreous detachment with retinal detachment several years ago. 10. osteoarthritis of his foot and knees. 11. gastroesophageal reflux disease 12. abnormal psa with negative biopsy in the past. 13. ocular toxoplasmosis as above 14. h/o sbo treated conservatively, felt to be r/t adhesions from the hemicolectomy. social history: social history: he is a pathologist in the breast center at [**hospital1 18**]. he is married with 2 adult children. - tobacco: none - alcohol: 1 wine/night - illicits: none family history: daughter with anaphylaxis r/t bee stings. physical exam: physical exam on admission: general: alert, oriented, no acute distress heent: sclera anicteric, eomi, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: a&o x3, cn grossly intact, mae. pertinent results: labs on admission: [**2123-3-20**] 05:27pm blood glucose-134* urean-22* creat-1.5* na-133 k-4.1 cl-98 hco3-23 angap-16 [**2123-3-20**] 05:27pm blood calcium-10.3 phos-2.6* mg-2.1 brief hospital course: dr. [**known firstname 449**] [**known lastname **] is a 62 yo male with history of recurrent retinal toxoplasmosis who presents for pyrimethamine desensitization because of angioedema related pyrimethamine. . # pyrimethamine desensitization - pyrimethamine desensitization was necessary to treat ocular toxoplasmosis. we monitored patient with 1:1 nursing while we completed desensitzation to po pyrimethamine per dr.[**last name (stitle) 20017**] protocol. of note, pt had already taken home dose of 60mg po prednisone at home, but was accidentally given another 60mg prior to the protocol starting. patient was then given iv benadryl and famoditine prior to desensitization. epi-pen was ordered to be at bedside but was not needed as pt tolerated the desensitization protocol well with no allergic rxn. patient advised to take pyrimethamine 12.5mg po qid to keep serum conc up. he is also so continue clindamycin qid and start leucovorin in the morning after d/c. patient was discharged home in stable condition on [**3-21**] at 2am (per his request, he did not wish to stay in the icu overnight). . # hypertension - normotensive throughout this stay. we continued his home hctz. . # hyperlipidemia - continued home simvastatin. . # code: full (discussed with patient) medications on admission: prednisone 60mg po x2 day start [**2123-3-19**]. clindamycin hcl - 300 mg capsule - 1 capsule(s) by mouth four times a day clindamycin hcl - 150 mg capsule - 1 capsule(s) by mouth four times a day hydrochlorothiazide - 25 mg tablet - 1 tablet(s) by mouth once a day leucovorin calcium - 10 mg tablet - 1 tablet(s) by mouth once a day metronidazole - 500 mg tablet - 1 tablet(s) by mouth three times a day, for gastroenteritis if needed for upcoming travel. pyrimethamine [daraprim] - 25 mg tablet - 1 tablet(s) by mouth twice a day on first day take total of 4 tablets for loading dose, then take 1 tablet twice daily thereafter simvastatin - 10 mg tablet - 1 tablet(s) by mouth every evening minoxidil - (prescribed by other provider) - dosage uncertain multivitamin,tx-minerals [multi-vitamin hp/minerals] - capsule - one capsule(s) by mouth daily discharge medications: 1. epinephrine (pf) 1 mg/ml solution sig: 0.3 mg injection once (once) as needed for shortness of breath, lip or throat swelling. : go to the ed or call 911 if you need to use this medication. . 2. clindamycin hcl 150 mg capsule sig: three (3) capsule po qid (4 times a day). 3. hydrochlorothiazide 12.5 mg capsule sig: one (1) capsule po daily (daily). 4. leucovorin calcium 10 mg tablet sig: one (1) tablet po once a day. 5. multivitamin tablet sig: one (1) tablet po daily (daily). 6. pyrimethamine 25 mg tablet sig: [**1-17**] tablet po four times a day. 7. metronidazole 500 mg tablet sig: one (1) tablet po three times a day as needed for gastroenteritis related to travel. 8. minoxidil topical 9. benadryl 25 mg capsule sig: [**1-17**] capsules po every six (6) hours as needed for rash, itching & lip swelling. discharge disposition: home discharge diagnosis: pyrimethamine desensitization ocular toxoplasmosis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear dr. [**known lastname **], it was a pleasure taking care of you during this admission. you were admitted to the icu for pyrimethamine desensitization. you tolerated the desensitization without any adverse reactions. you will need to continue to take the pyrimethamine 25mg tabs, [**1-17**] tab by mouth 4 times daily. if more than 24 hours elapse between any two doses, it is possible that you could develop an allergic reaction to the medication and the desensitization protocol will need to be repeated. your creatinine was noted to be slightly elevated, which you said is common for you. you were encouraged to drink plenty of fluids. followup instructions: please follow up with your allergist, your infectious disease doctor and your primary care doctor in the next 1-2 weeks to determine total course of your pyrimethamine, clindamyacin and leukovorin. [**first name11 (name pattern1) **] [**last name (namepattern4) 3559**] md, [**md number(3) 3560**]",0
152,"admission date: [**2156-12-27**] discharge date: [**2156-12-31**] date of birth: [**2082-2-26**] sex: f service: medicine allergies: penicillins / aspirin attending:[**first name3 (lf) 5827**] chief complaint: shortness of breath major surgical or invasive procedure: none history of present illness: 74yo f with htn, dm, cva, cri and hx of frequent falls s/p orif [**11-30**] who presented from her nh ([**hospital3 2558**]) because she was noted to be unresponsive with pulse ox of 64%. the pt is a poor historian, therefore the bulk of the note was created by [**name9 (pre) 103558**] from the ed as well as information obtained by the primary team. as per report, the pt was responsive and a&o x3 when she was found by ems. she does note that she started feeling ""lousy and dizzy"" for several days pta. she reported feeling short of breath several days prior to admission on the morning of. she does not recall the period of her unresponsiveness. the pt was unable to elaborate further. she denies dysuria, cough, diarrhea, n/v, ab pain, fevers, pain at all, ha, cp. all of the above information was by report. in ed, the pt was found to have a pulse ox of 85%-->95% on 100%nrb-->94% on 4l. the pt was given asa and bb iv upon arrival in the ed for her sob. the pt was found to have a rul infiltrate on cxr and was given ceftriaxone 1 gm iv x 1 and azithro 500 mg iv x1. her ua was dirty with 50 wbc, +nitrate, but large amt of epithelial cells. her head ct was negative, as were lenis. pt noted to be hypertensive with sbp up to 200s and was given metoprolol 5 mg iv x3. the pt was seen in the ed by the medicine team and while awaiting a bed, developed tongue swelling and worsening difficulty breathing. the pt was then given solumedrol and benadryl 25mg once iv in the ed for presumed allergic reaction and transferred to the icu for further management. in the [**hospital unit name 153**], the pt reports worsening of herbreathing but denied any overt chest pain, palpitations, abdominal pain, n/v/d. past medical history: past medical history: 1. hypertension. 2. diabetes mellitus. 3. history of paranoid schizophrenia. 4. history of frequent falls. 5. history of hypercholesterolemia. 6. iron deficiency anemia. 7. status post cerebrovascular accident in [**2149**]. 8. history of granulomatous hepatitis in [**2139**]. 9. chronic renal insufficiency with a baseline creatinine of 3.2 10. oa 11. recent orif social history: no etoh or ivda. no smoking. family history: nc physical exam: vs: tm 98.2 hr 75-82 bp 176-206/82-92 r 16-18 sat 85%ra-->94%4l nc gen: pleasant elderly aa female in nad, a and ox 2 (unable to give time/date). heent: eomi, anicteric, pupils contricted, muddy sclerae, dry mm, white cereal noted in back of op neck: no lad, no jvd, no bruits cv: rrr, s1, s2, no m/r/g appreciated chest: bibasilar rales, mild end expiratory diffuse wheezes, decreased bs throughout, no dullness to percussion abd: obese, soft, nt, nd, bs+ ext: wwp, 2+pitting in lle up to knee, staples on l thigh c/d/i, full dp/pt pulses neuro: cn ii-xii grossly intact, grip strength 4-/5 bl, 2+hip extension (unclear if pt was following commands) pertinent results: labs on admission [**2156-12-27**] 10:00am urine color-straw appear-hazy sp [**last name (un) 155**]-1.009 [**2156-12-27**] 10:00am urine blood-sm nitrite-neg protein-100 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-8.0 leuk-mod [**2156-12-27**] 10:00am urine rbc-[**2-13**]* wbc->50 bacteria-mod yeast-none epi-[**5-21**] renal epi-0-2 [**2156-12-27**] 10:00am urine 3phosphat-few [**2156-12-27**] 09:55am glucose-220* urea n-57* creat-2.8* sodium-134 potassium-5.4* chloride-100 total co2-24 anion gap-15 [**2156-12-27**] 09:55am alt(sgpt)-26 ast(sgot)-26 ck(cpk)-34 alk phos-232* amylase-56 tot bili-0.3 [**2156-12-27**] 09:55am lipase-67* [**2156-12-27**] 09:55am ctropnt-0.16* [**2156-12-27**] 09:55am ck-mb-notdone [**2156-12-27**] 09:55am albumin-3.4 [**2156-12-27**] 09:55am wbc-11.7* rbc-3.50* hgb-10.0* hct-31.0* mcv-89 mch-28.6 mchc-32.3 rdw-14.5 [**2156-12-27**] 09:55am neuts-89.0* lymphs-7.8* monos-2.3 eos-0.7 basos-0.1 [**2156-12-27**] 09:55am plt count-682*# [**2156-12-27**] 09:55am pt-13.5* ptt-21.9* inr(pt)-1.2 . labs on discharge [**2156-12-30**] 06:10am blood wbc-12.6* rbc-3.15* hgb-9.0* hct-28.5* mcv-90 mch-28.6 mchc-31.7 rdw-15.4 plt ct-474* [**2156-12-28**] 01:10am blood neuts-98.1* lymphs-1.4* monos-0.5* eos-0.1 baso-0 [**2156-12-30**] 06:10am blood plt ct-474* [**2156-12-28**] 01:10am blood pt-13.9* ptt-25.4 inr(pt)-1.3 [**2156-12-30**] 06:10am blood glucose-151* urean-69* creat-2.8* na-134 k-5.2* cl-99 hco3-28 angap-12 [**2156-12-30**] 06:10am blood calcium-8.8 phos-3.8 mg-3.8* . cardiac enzymes [**2156-12-27**] 09:55am blood ctropnt-0.16* [**2156-12-27**] 09:55am blood ck(cpk)-34 [**2156-12-27**] 04:29pm blood ck-mb-notdone ctropnt-0.13* [**2156-12-27**] 04:29pm blood ck(cpk)-41 [**2156-12-28**] 01:10am blood ck-mb-3 ctropnt-0.11* [**2156-12-28**] 01:10am blood ck(cpk)-38 . radiology hip unilat min 2 views left [**2156-12-30**] mild-to-moderate degenerative change involves the right hip joint. the bilateral sacroiliac joints and the pubic symphysis is unremarkable. vascular calcifications are noted. impression: orif left intertrochanteric femur fracture. brief hospital course: a/p: 74yo f with htn, dm, cva, recent orif of hip fx found unresponsive with desat to 64%, found to have rul pna, uti and ?anaphylactic reaction. . # anaphylaxis: given the patient's allergy to penicillin and tongue swelling after the administration of ceftriaxone, there was concern that she was having an anaphylactic reaction. the patient received solemdrol and benadryl. the patient was observed in the [**hospital unit name 153**]. the patient was then transferred to the medicine service where she was monitored for respiratory compromise. the patient never decompensated. her o2sats were stable. at the time of discharge she had decreased swelling of her tongue. #pna: on cxr the patient was found to have a rul infiltrate. she was initially treated with azithromycin and ceftriaxone. however given her adverse reaction to the ceftriaxone, this was discontinued and the patient was started on vancomycin. given the patient's residence at [**location (un) **], she was treated as if she had a community acquired pneumonia. the patient also has a h/o pseudomonal uti. if the she had decompensated, the plan was to start an abx such as meropenem for wider coverage. . of note the patient vanc level was low at 10.5 on [**2156-12-29**]. the patient was scheduled for dosing on the [**12-29**]. at the time of discharge our recommendations will be to check another vanc level prior to dosing. #. uti: pt seems to have a dirty ua with 50 wbc, +nitrates, mod bacteria. repeat ua showed greater than 62 wbcs. at the time of discharge the patient was being treated with levofloxacin. #sob: the patient was treated for her pna. if her condition deteriorated we would have considered chf secondary to a hypertensive heart. the differential would have also included a pe given the patient's recent orif. however, the patient had been maintained on lovenox. as discharge approached the patient was weaned off of oxygen. her o2sat was 95% ra. . of note the patient was ruled out for an mi. the patient was monitored on telemetry in the icu. an ecg was done which was normal. . #htn: the patient was maintained on lopressor, imdur and hydralazine. her hydralazine was increased to 50 tid because of elevated pressures. at the time of discharge her blood pressure was stable. . #. cva prevention: tight glycemic and bp control was maintained. the patient also received a statin. . #. acute on cri: the patient has a history of chronic renal insufficiency. with low urine outputs she received boluses and diuresed appropriately. the patient's creatinine remained at baseline. following her orif her creatinine has ranged from 2.8 to 3.2. #. diabetes: the patient was maintained on insulin sliding scale. . #. s/p orif the patient was seen by dr. [**last name (stitle) 57373**] during her hospitalization. a repeat hip film was done which showed mild to moderate changes involving the r hip joint and orif left intertrochanteric femur fracture. followup with dr. [**last name (stitle) 1005**] was set up prior to discharge. . #anemia: the pt has a history of iron deficiency anemia, in addition, has cri. she was maintained on iron supplements, epogen and her stools were guaiac negative. her hct was greated than 27 throughout her course. the patient did not require blood transfusions. . #schizophrenia: the patient's condition remained stable. . #fen: due to her tongue swelling the patient was kept npo. as her swelling went done her renal, diabetic, cardiac diet was resumed. the patient was seen by speech and swallow and they recommended thin liquids and soft foods. the patient will need further evaluation by the speech and swallow specialists at [**hospital3 2558**]. the patient's lytes were repleted as needed. she also received kayexylate for hyperkalemia. her k peaked at 5.9 during this admission, at the time of discharge it was 5.2. . #line: patient had picc line placeon [**2156-12-30**] for abx . #ppx: protonix, bowel regimen, sq lovenox . #code status: full code . #communication: [**name (ni) 102399**] [**name (ni) 98752**] (sister) [**telephone/fax (3) 103559**] (neither phone number connected to sister) . #dispo: [**hospital3 2558**] medications on admission: 1. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 2. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. diltiazem hcl 240 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). 7. atorvastatin 20 mg tablet sig: 1.5 tablets po daily (daily). 8. olanzapine 5 mg tablet sig: one (1) tablet po hs (at bedtime). 9. epoetin alfa 3,000 unit/ml solution sig: 3000 (3000) units injection qmowefr (monday -wednesday-friday). 10. isosorbide mononitrate 30 mg tablet sustained release 24hr sig: three (3) tablet sustained release 24hr po daily (daily). 11. hydralazine 25 mg tablet sig: three (3) tablet po q6h (every 6 hours). 12. enoxaparin 30 mg/0.3 ml syringe sig: thirty (30) mg subcutaneous q24h (every 24 hours) for 4 months. mg 13. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours). 14. metoprolol tartrate 50 mg tablet sig: three (3) tablet po tid (3 times a day). 15. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 18. ssi 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. isosorbide mononitrate 30 mg tablet sustained release 24hr sig: three (3) tablet sustained release 24hr po daily (daily). 3. metoprolol tartrate 50 mg tablet sig: three (3) tablet po tid (3 times a day). 4. epoetin alfa 4,000 unit/ml solution sig: one (1) injection qmowefr (monday -wednesday-friday). 5. olanzapine 5 mg tablet sig: one (1) tablet po hs (at bedtime). 6. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 7. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po qod (). 8. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed. 9. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours). 10. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. 11. enoxaparin 30 mg/0.3 ml syringe sig: one (1) subcutaneous q24h (every 24 hours). 12. insulin lispro (human) 100 unit/ml solution sig: asdir subcutaneous asdir (as directed). 13. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h (every 4 to 6 hours) as needed. 14. levofloxacin 250 mg tablet sig: one (1) tablet po q48h (every 48 hours) for 10 days. disp:*5 tablet(s)* refills:*0* 15. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily). 16. atorvastatin 10 mg tablet sig: three (3) tablet po daily (daily). 17. hydralazine 50 mg tablet sig: one (1) tablet po q8h (every 8 hours). 18. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) intravenous q48h (every 48 hours) for 5 days. disp:*5 units* refills:*0* 19. diltiazem hcl 240 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po once a day. disp:*30 tablet sustained release 24hr(s)* refills:*2* discharge disposition: extended care facility: [**hospital3 2558**] - [**location (un) **] discharge diagnosis: -community acquired pneumonia -urinary tract infection -anaphylaxis discharge condition: good vitals stable patient eating discharge instructions: please seek medical services immediately if you should experience and shortness of breath, fevers, chills or any other worrisome symptom. . please continue taking your medications as prescribed. followup instructions: you are to followup with your primary care physician [**name initial (pre) 176**] [**12-13**] week of discharge. . provider: [**first name11 (name pattern1) **] [**last name (namepattern1) 2235**], md phone:[**telephone/fax (1) 1228**] date/time:[**2157-2-8**] 1:00 completed by:[**2157-2-14**]",1
153,"admission date: [**2184-9-13**] discharge date: [**2184-10-16**] service: preoperative diagnosis: 1. left upper lobe mass. secondary diagnoses: 1. polycythemia [**doctor first name **]. 2. thyroid cancer. 3. history of atypical transient ischemic attacks. 4. carotid stenosis. 5. hypertension. 6. status post thyroidectomy. 7. status post total abdominal hysterectomy. 8. status post cholecystectomy. postoperative diagnoses: 1. left upper lobe mass. 2. polycythemia [**doctor first name **]. 3. thyroid cancer. 4. history of atypical transient ischemic attacks. 6. carotid stenosis. 7. hypertension. 8. status post thyroidectomy. 9. status post total abdominal hysterectomy. 10. status post cholecystectomy. procedures performed: (on [**2184-9-13**]) 1. left upper lobe wedge resection. 2. bronchoscopy. 3. completion of left upper lobectomy. 4. mediastinal lymph node dissection. 5. excision of thymoma. 6. pleural flap pedicle closure. indications for admission: ms. [**known lastname **] is a fairly active 82-year-old woman who presented with a history of chest pain. she was evaluated and ruled out for a myocardial infarction. her workup included radiographs that demonstrated a mass in the left upper lobe and was confirmed by computed tomography scan. the risk, benefits, and alternatives were discussed with her at length. we felt that this was most likely a lung cancer of some type, and she might benefit from resection even given her advanced age. she had some concerns about this, and was discussed them for quite some time. she also has a history of some atypical visual changes; possibly transient ischemic attacks, and a history of polycythemia [**doctor first name **]. she underwent a preoperative evaluation including attempted snipping of her carotid artery by dr. [**first name8 (namepattern2) **] [**name (stitle) 1132**] here. eventually, she was felt not to be a safe candidate during the angiogram. she was placed on aspirin and plavix at that time. after this procedure, her lung mass was again addressed with her. she consented to undergo definitive treatment. past medical history: her previous medical history as above. medications on admission: her medications preoperatively were plavix, aspirin, hydrea, levoxyl, hydrochlorothiazide, and metoprolol. physical examination on presentation: her physical examination was otherwise unremarkable. hospital course: please note that this dictation is being performed several months after the patient's date of death. it was difficult to determine who the responsible resident was for dictating this discharge summary, and i am going to complete it at this time. my recollection at this time is being reinforced by the patient's chart; although, for the exact details i would refer to the medical record. the patient underwent the above-mentioned procedure on [**2184-9-13**]. postoperatively, she was monitored in the intensive care unit. for the first two postoperative days, she was monitored in the postanesthesia care unit for some (1) respiratory lability and (2) relative hypotension requiring [**name (ni) 103585**] drip at low-to-moderate doses to maintain her blood pressure. we were especially aggressive about this given her previous history of atypical transient ischemic attacks. on or about the third postoperative day, the patient manifested signs of respiratory distress. a chest x-ray demonstrated collapse of the remaining left lower lobe, and the patient was intubated. the patient was transferred to the cardiac surgery recovery unit, and full monitoring was performed. over approximately the subsequent second to nine days, the patient showed steady slow improvement. she did not show any evidence of multiorgan failure, and her pulmonary symptoms slowly resolved. she was bronchoscoped on a daily basis with the finding of thick secretions as well as mucosal edema. interventional pulmonology was consulted at this time, and they performed the majority of the bronchoscopies. she treated with prophylactic antibiotics, and several cultures did not prove her to have a pneumonia. she was slowly weaned from ventilatory support by approximately postoperative day nine, and she was extubated. at this point, we re-evaluated her swallowing given the prolonged intubation and previous surgery, and thought this would be prudent. her swallowing evaluation showed gross aspiration. she was made nothing by mouth and treated with nutrition alternatives. around postoperative day twelve, she still manifested an increased white blood cell count despite being afebrile. she was treated with prophylactic antibiotics. however, increasingly over the next one to two weeks, this was felt actually to be related to withdrawal of her hydrea medication for polycythemia [**doctor first name **]. we had a long discussion with her hematologist about this, and this was felt eventually to be the most likely cause of her leukocytosis. clinically, she did not appear infected nor septic. her pulmonary status, however, continued to be tenuous requiring aggressive pulmonary toilet. because of intermittent left lower lobe collapse and effusion on that side, interventional radiology was consulted and placed a small drain in the left pleural space on postoperative day fourteen for effusion. the culture did not grow out any bacteria on final analysis. around this time, ear/nose/throat was consulted for her swallowing difficulties, and she was found to have bilateral vocal cord paresis. they felt that this would improve with time and simply keeping her nothing by mouth would suffice. over the subsequent two weeks, the patient showed gradual improvement; although, she was not yet able to swallow. at the end of [**month (only) 359**] (around [**9-30**]), gastroenterology was consulted for placement of percutaneous endoscopic gastrostomy tube. it was around this time she also had manifest signs of increasing blood pressure lability. she had an acute decompensation around [**10-1**] or [**10-2**], and a percutaneous endoscopic gastrostomy tube was deferred for a later date. cardiology was involved in her management, and pressors were needed to support her blood pressure. the patient had an elevation in her troponin to a level of 18, and an echocardiogram which showed severe global dysfunction of her left ventricle. this was a significant change from her preoperative which essentially showed a normal ventricle. she also had some arrhythmias at this time with some ventricular as well as atrial arrhythmias. a cardiac catheterization was performed at that time which surprisingly showed completely normal coronary arteries. it was unclear as to the etiology of her acute decompensation in cardiac function, and this may have been related to some adverse reaction to a drug (which eventually remained undetermined). by [**10-6**], the patient was showing steady progress. her repeat echocardiogram actually showed a normal left ventricle. she was re-evaluation at this time by ear/nose/throat and felt to still be at high risk and was kept nothing by mouth at this time. again, at this time, the patient had no signs of sepsis or infection. on or about [**10-9**], the patient had an episode of monocular blindness and was consulted by the neurology service. she had previously had a workup for this; both as an inpatient earlier in her hospital stay and as mentioned preoperatively (including an aborted attempt at stenting her carotid). at this time, the treatment recommended was maintaining her blood pressure at a higher rate; and this was done with a dopamine infusion. neurologically, she was otherwise fairly nonfocal and was gaining strength each day. by [**10-13**], the patient was showing improvement with physical therapy, and speech and swallow evaluation showed significant improvement and no evidence of aspiration, and she was placed on a diet with aspiration maneuvers as described by the speech therapy department. it should be mentioned that the patient had an increasing interstitial pattern on her chest x-rays. it was unclear as to the etiology of this. the differential included infection versus inflammatory connective tissue versus lymphatic spread of tumor. her pathology showed bronchoalveolar carcinoma well differentiated as well as a noninvasive thymoma. therefore, we felt that neoplasm was probably unlikely. she was eventually started on prophylactic antibiotics, but on [**10-14**] the patient had an acute decompensation of an extremely severe nature. the patient showed evidence of respiratory distress and was intubated immediately by anesthesia. her hemodynamics became progressively/rapidly decompensated, and fluids and pressors were necessary for support. immediately, invasive hemodynamic monitoring lines were placed including a swan-ganz catheter that was consistent with septic physiology. aggressive treatment was performed at this time to optimize her cardiac, respiratory, pulmonary, and renal function. we had a long discussion with her family at this time as to the events that occurred, and sought their opinion as to what she would prefer for her management. we agreed that aggressive management would continue to see if she showed dramatic improvement. if not, we would consider alternative strategies. over the subsequent two day, the patient showed absolutely no improvement with progression to multiorgan dysfunction. after a long discussion with the patient's family (including her son who was her health care proxy), they felt that the patient would not want to persist with this mode of life support given her age and extremely poor prognosis. at this time, withdrawal of support was initiated and comfort measures made, and the patient expired. the family was present during this time. dr. [**last name (stitle) 175**] was present and participated throughout all the decision making processes. discharge disposition: death. [**first name11 (name pattern1) 177**] [**last name (namepattern4) 178**], m.d. [**md number(1) 179**] dictated by:[**last name (namepattern1) 44639**] medquist36 d: [**2185-1-7**] 15:51 t: [**2185-1-11**] 11:51 job#: [**job number **]",1
154,"admission date: [**2177-11-25**] discharge date: [**2177-11-26**] date of birth: [**2107-11-9**] sex: f service: micu-green reason for admission: the patient was transferred from outside hospital (vent-core), because of acute renal failure as well as a new serious rash. history of present illness: this is a 70 year old woman with a history of breast cancer, chronic obstructive pulmonary disease, severe refractory hypertension, type 2 diabetes mellitus, and chronic renal insufficiency who presents from [**hospital 103101**] rehabilitation, followed there by the pulmonary interventional fellow, [**name (ni) **] [**name8 (md) **], m.d., with a desquamating rash, serum eosinophilia as well as recent acute renal failure. the patient was discharged to this rehabilitation from [**hospital1 69**] in [**2177-7-10**]. prior to the admission to [**hospital1 346**] medical intensive care unit from [**7-3**] until [**2177-8-1**], she was also here in early [**month (only) **] as well. in the first admission, she was admitted for a chronic obstructive pulmonary disease flare and was noted to have bilateral pleural effusions and pericardial effusions with tamponade physiology. this was tapped under ultrasound guidance and found to be exudative with negative cytology and [**first name8 (namepattern2) **] [**doctor first name **] of 1.160. she was then readmitted nine days later with shortness of breath again, thought to be a chronic obstructive pulmonary disease flare and was treated with nebulizers, lasix and solu-medrol. she was found to have tamponade physiology on a transthoracic echocardiogram, underwent balloon pericardiotomy and intubated for airway protection. an ultrasound guided thoracentesis on [**7-4**] for a left pleural effusion which was found to be transudative was performed and the patient was extubated successfully. five days later, both the pleural effusion and the pericardial effusions reaccumulated requiring re-intubation on [**7-9**]. the patient went to the operating room for a pericardial window, a left chest tube and a left pleurodesis. after this, she was unable to extubate and was then returned to the medical intensive care unit. failure to wean in the medical intensive care unit was secondary to diaphragmatic weakness and she was noted to have critical care polyneuropathy/myopathy per emg on [**2177-7-24**]. she underwent tracheotomy on [**2177-7-17**]. the cause of the pleural and pericardial effusions are unknown. the work-up was basically negative; there were no malignant cells found in either of the fluids and the pericardial window biopsy was negative. also, rheumatology evaluated her and thought it was not secondary to a rheumatological cause because her admission [**doctor first name **] on [**7-6**] was negative (however, she had positive [**doctor first name **] on [**2177-7-25**] times two). her pulmonary status improved and the effusions remained stable so she was discharged to vent-core on [**2177-8-1**]. she did well at the rehabilitation and her course there was actually unknown to us at this point, however, we do know that she was unable to be weaned off of her ventilator. she was currently on cmv with a total volume of 500, respiratory rate of 12 and an fio2 of 40% and had recently failed a ps trial secondary to tachypnea and low volume. recent events at the rehabilitation are summarized below: we know that she recently finished a course of vancomycin and cefepime on [**11-17**], which was begun empirically secondary to a fever. at this time, we do not know the length of time she was on either of these antibiotics. she was recently restarted on lisinopril on approximately [**11-16**]. she does have a history of her creatinine going up on ace inhibitors in the past, however, she was having blood pressures up to the 240s and an attempt was made to restart her on lisinopril which she had not been on since [**month (only) 216**]. her creatinine upon discharge from [**hospital1 190**] ranged from 1.0 to 1.5. she briefly had some elevations of the creatinine into the 2.4 range secondary to acute renal failure from intravenous contrast. they restarted the lisinopril at 10, went up to 20, and discontinued her lisinopril on [**11-20**], as her creatinine had started to rise. it was 3.2 on [**11-21**] and then increased to 3.6 at the outside hospital on [**11-24**]. renal did evaluate her while she was at the rehabilitation and they suggested dialysis as well as an increase in her lasix. she did not undergo dialysis at that time. then, on [**11-21**], a rash was noted to have started that was initially limited and mild but then she underwent desquamation of her skin associated with diffuse erythema and edema. she was also noted to have an eosinophilia since [**2177-10-17**]. we know that her serum eosinophils were 16% on [**11-19**] and had decreased to 12% on [**11-24**]. of note, she had also been on prednisone for an unknown reason. at the rehabilitation it was decided to start weaning this down from 10 mg to 5 mg one week ago. according to the physicians that took care of her at the rehabilitation, her only new medications were lisinopril from approximately [**11-16**] until [**11-20**]. she had been previously on that but not since [**month (only) 216**]. she was also recently started on amlodipine however, it was related that this was started on [**11-22**], after the rash had appeared. all her other hypertensive medications she had been on for quite some time, and the only other recent medications were her antibiotics, vancomycin and cefepime, that were discontinued on [**11-17**], when the course was finished. review of systems: the patient can nod her head with responses and denied pain and shortness of breath at time of admission. past medical history: 1. chronic obstructive pulmonary disease: restrictive lung disease with reactive airway disease. 2. status post tracheostomy on [**7-17**] and peg placement on [**2177-7-28**]. her tube feeds are at a goal of 35 cc per hour. she has been unable to be weaned off her ventilator at vent-core. 3. pericardial effusion / tamponade that was found to be exudative with negative cytologies. status post window placement on [**2177-7-9**]. 4. bilateral pleural effusions, transudative, status post left pleurodesis on [**2177-7-9**]. 5. breast cancer (dcif), status post total mastectomy, er-pos, stage 2, no radiation, n0 m0, and currently off tamoxifen. 6. severe hypertension, on five medications. 7. type 2 diabetes mellitus, previously on oral hypoglycemics and now requiring insulin. 8. chronic renal insufficiency secondary to diabetes mellitus with nephrotic range proteinuria. 9. acute renal failure secondary to intravenous dye in [**2177-7-10**]. also had a history of elevated creatinine secondary to ace inhibitors. 10. thalassemia trait. 11. questionable history of osteogenesis imperfecta. 12. legal blindness; she has a left eye prosthesis as well. 13. urinary incontinence. 14. echocardiogram results from [**2177-6-9**] revealed a right ventricular wall clot/tumor with an ejection fraction of 58%. her latest echocardiogram at [**hospital1 188**] on [**2177-7-22**], revealed an ejection fraction of greater than 65%, mild lae, mild symmetrical left ventricular hypertrophy with normal cavity size and regular wall motion; mild thickened atrial valve and mitral valve leaflets; moderate pulmonary hypertension; small to moderate pericardial effusion predominantly over the right ventricle. no change when compared to the prior study of [**2177-7-17**]. 15. noted to have vancomycin resistant enterococcus in her urine on [**7-23**]. 16. left ocular paresthesia. 17. anemia; it appears that her baseline hematocrit is usually in the high 20s. 18. spap with 2% gamma band, likely consistent with mgus. upap revealed multiple protein bands without even predominating. 19. urine positive for pseudomonas according to the rn at vent-core. 20. history of methicillin resistant staphylococcus aureus - question in her sputum. allergies: no known drug allergies. medications on transfer to [**hospital1 **]: 1. amlodipine 10 mg q. day p.o., recently began on [**11-22**], after the rash had appeared. 2. hydralazine 100 mg four times a day; she has been on this medication for a while. please note that the vent-core sheets report that she began this medicine on [**11-21**], however, this was only a renewal according to dr. [**last name (stitle) **]. 3. lasix 40 mg twice a day. 4. nph 20 units twice a day. 5. h2o 125 cc three times a day. 6. benadryl 25 mg q. eight hours. 7. subcutaneous heparin 5000 twice a day. 8. prednisone 5 mg q. day. 9. protein soy supplement, two scoops in the feeding tube q. eight hours. 10. nepro 3/4 strength tube feeds 35 cc per hour. 11. clonidine 0.3 three times a day. 12. bisacodyl 10 mg q. day p.r.n. 13. regular insulin sliding scale with humulin. 14. lopressor 100 mg four times a day. 15. labetalol 200 mg four times a day. 16. isosorbide dinitrate 40 mg q. eight hours. 17. sublingual nitroglycerin p.r.n. 18. protonix 40 q. day. 19. epogen 40,000 units subcutaneously weekly. 20. brimonidine 0.2% solution, one drop bilaterally q. eight hours. 21. ditolamide one drop solution to each eye three times a day. 22. ativan 1 mg q. eight hours. 23. calcium carbonate 500 mg q. eight hours. 24. ipratropium and albuterol mdi four puffs q. four hours p.r.n. allergies: the patient has no known drug allergies. social history: remote history of tobacco use. no current alcohol use. she has a sister who is demented. she previously had lived with her son and her son whose name is [**name (ni) **] [**name (ni) 16093**] is her primary contact, [**telephone/fax (1) 103102**]. he also has a brother, [**name (ni) **] [**name (ni) **], who is a second contact, whose phone number is [**telephone/fax (1) 103103**]. physical examination: temperature 98.4 f.; heart rate 62; blood pressure 163/43, respiratory rate 12 to 18, 100% o2 saturation; vent settings are assist control, total volume 500, respiratory rate 12, o2 saturation 40% with 5 of peep. in general, the patient opens eyes, nods yes and no to questions. she is an elderly african american female. heent: she has a left eye paresthesia, right eye with questionably sclerae clouded over. sclerae anicteric. oropharynx is clear; there are no mucosal lesions. mucous membranes were moist. neck: tracheostomy is in place. neck is supple. cardiovascular: regular rate and rhythm, normal s1 and s2. respirations: decreased breath sounds at bases. occasional wheeze heard in the left anterior aspect of the well healed abdomen. normoactive bowel sounds. peg is in place. soft, nontender, nondistended. extremities with plus two pitting edema diffusely with no cyanosis or clubbing. extremities are warm; plus two dorsalis pedis is felt on the left, however, could not detect distal pulses on the right extremity. skin: as described by the dermatologic consultation later in the evening; generalized moderate non-colorous erythema with marked desquamation and areas that show evidence of good re-epithelialization. multiple eroded areas in the intertrigous areas of the neck, axillae, breasts and groin. approximately 30% of her back showed superficial erosions and skin sloughing. positive perianal punched out ulcers. also of note, the conjunctivae appears slightly erythematous but on gross examination there were no conjunctival or corneal erosions. neurologic: moves all four extremities. pertinent laboratory: from vent-core on [**11-19**], white blood cell count 24, hematocrit 29.2, platelets 329, mcv of 65 with a differential of 72% polys, 5% lymphocytes, 6% monocytes, 16% eosinophils and 1% basophil. from vent-core on [**11-24**], revealed a sodium of 134, potassium of 4.4, chloride of 103, bicarbonate of 22, bun of 130, a creatinine of 3.6 (was 2.4 on [**11-21**] and 3.2 on [**11-19**]). glucose of 111, calcium of 8.6. reportedly had a serum eosinophil percentage of 12. upon admission to [**hospital1 69**], white blood cell count 13.2, hematocrit of 30.1 with an mcv of 66, platelets of 315, pt of 14.4, inr of 1.4, ptt of 28.3. sodium of 135, potassium of 4.9, chloride of 102, bicarbonate of 20, bun of 135, creatinine of 3.6, glucose of 201, calcium of 9.0 corrected to 10.1, phosphorus of 3.4, magnesium of 2.5. alt of 14, ast 22, ld of 233, alkaline phosphatase of 166 which is mildly elevated. total bilirubin of 0.5, albumin of 2,6, lipase of 14, amylase of 20. studies were: 1) portable chest x-ray revealed fairly marked enlargement of the cardiac silhouette. predominantly left ventricle. pulmonary [**hospital1 56207**] are predominant in the upper zones and some left ventricular failure cannot be excluded. loss of translucency at both lung bases; left diaphragm is elevated. tracheostomy is in satisfactory position. probably bilateral pleural effusions with the question of a left lower lobe infiltrate/atelectasis. 2) renal artery ultrasound from [**2177-6-9**] at [**hospital1 346**] was notable to have a right kidney size of 9.4 and a left kidney size of 9.3. the doppler's were unable to be done. 3) renal artery ultrasound done on [**2177-11-26**], revealed no hydronephrosis, patency of the [**last name (lf) 56207**], [**first name3 (lf) **] the doppler's were not done. the right kidney size was 9.6. the left kidney was unable to be estimated for size due to positional factors, however, it looks grossly normal. hospital course: mrs. [**known lastname 5261**] was admitted to the medical intensive care unit. a dermatology consultation was obtained on the evening of the 17th. their assessment that this was represented likely resolving [**doctor last name **]-[**location (un) **] syndrome versus ten and it seems that it is most consistent with ten. she does show significant re-epithelialization. there is no calor, no tenderness, no bullae evident on examination. her eosinophils have dropped from 16% to 12 in the last few days which suggests improvement in her drug hypersensitivity. these and the fact that her prior antibiotics have now been discontinued, suggests that she is resolving from a prior ten. the most likely culprit for this adverse reaction includes lisinopril which was discontinued on [**11-20**], secondary to the development of acute renal failure. other culprits include vancomycin and the cefepime that had been on board since [**8-1**] and were discontinued on [**11-17**]. cefepime was more likely than vancomycin to cause this adverse drug reaction. these antibiotics should be avoided as well as all ace inhibitors. the amlodipine was also recently added after her rash had begun and at this point until we get the actual medical sheets from the rehabilitation facility, we are holding this amlodipine as well. i have spoken to [**hospital3 105**] vent-core unit, [**location (un) 1773**], where the phone number is [**telephone/fax (1) 26091**], and a nurse there was going to fax the start and stop dates of all the medications she was on during her admission there. we have yet to receive that fax. they also recommended checking urine eosinophils which are currently pending, serum eosinophils which did return on her admission as only 3%, however, the morning of transfer have increased to 7%. liver function tests which were normal except for a slightly elevated alkaline phosphatase as well as ggt of 68 and a bun and creatinine that were at 136 and 3.6 on the morning of [**11-26**]. it was also recommended to follow her electrolytes twice a day. her full electrolytes panel the day of transfer was a sodium of 137, potassium 4.7, chloride 103, bicarbonate of 20, bun of 136, creatinine of 3.6, glucose of 208, calcium of 8.6, phosphorus of 3.2, magnesium of 2.4. of note, she also had a white blood cell count of 13.1, hematocrit of 31.3, platelets of 324, with a differential of 78% neutrophils, 1% bands, 7% lymphocytes, 6% monocytes, 7% eosinophils and 1% metas. for her skin we were placing xeroderm patches as well as using bactroban instead of bacitracin to her wounds. the next morning, dermatology obtained two 5 mm skin punch biopsies at the left parasternal line under sterile conditions and were sent to pathology for a diagnosis. an epidermal jelly-roll from epidermis adjacent to fresh erosion also sent in, however, on dermatology fellow's examination, there were no bullae, only erosions. the biopsy sites were sutured with #5 ethilon, two sutures were used at each site. these sutures will need to be removed in approximately two weeks. the above procedure was done by [**first name8 (namepattern2) **] [**last name (namepattern1) 103104**], pager number [**serial number 103105**] [**hospital1 756**]. they also recommended swabbing the neck erosions for cultures which look slightly purulent. other entities on differential diagnoses include staphylococcus skin syndrome, which is possible but probably not likely in this case. we did sent pan-cultures for urine, sputum and blood. we also started her on normal saline fluids at a rate of only 60 cc per hour for now. we were concerned that she might have had some congestive heart failure on her chest x-ray. also, she had a very small intravenous line that was in her finger and we were worried about losing access overnight. her intakes and outputs over an eight hour period overnight was 925 cc in with a urine output of 305 cc per hour. her other work-up for the rash revealed an esr of 20 which is high normal, a tsh and [**doctor first name **] which are pending, and a rheumatoid factor which returned as negative. 2. infectious disease: she was placed on precautions upon admission here for a history of vre in the urine, which was treated with linezolid in [**2177-6-9**]. also with a history of methicillin resistant staphylococcus aureus. all antibiotics were held at this point and her white blood cell count, though, was slightly elevated (she is on prednisone), which was basically normal and she was afebrile. dermatology also suggested getting viral cultures of the punched out lesions of the peri-rectal area that they saw. other infectious disease issues were that the sputum culture gram stain had returned with greater than 25 polys, less than 10 epithelials, however, four plus gram negative rods. her secretions were slightly yellow and thick but as she was afebrile and was in the setting of an acute rash, session: did not start antibiotics. her blood cultures from [**11-25**] were no growth to date so far. 3. renal: the patient is in acute renal failure; likely multi-factorial including recent ace inhibitor, pre-renal causes secondary to a recent increased dose of her lasix, like maybe congestive heart failure, poor oncotic pressure secondary to low albumin and nephrotic range proteinuria. likely ain, especially given increased peripheral eosinophils as well as rash. we decided to send her urine for electrolytes as well as urine for urine urea to check an fe urea. these are pending at the time of this dictation. urine eos were sent. we obtained a renal ultrasound and the results are listed above. she was put in for a cardiac echocardiogram and we decided to rule out myocardial infarction in case myocardial infarction with congestive heart failure had occurred in this case. 4. hypertension: the patient was continued on hydralazine 100 four times a day; clonidine 0.3 three times a day; metoprolol 100 four times a day, labetalol 200 q. six hours; isosorbide 40 three times a day, but the amlodipine was held. her blood pressure had ranged from 143 to 174 systolic overnight. it was decided to initiate a work-up for the secondary causes of her hypertension. it appears that since her kidneys are both of normal size, even though dopplers were unable to be done, that the likelihood of renal artery stenosis was maybe low, however, the test is not definitive. at this time, we are avoiding all ace inhibitors. 5. chronic obstructive pulmonary disease: we are continuing albuterol and atrovent mdi. 6. for diabetes mellitus type 2, we initiated four times a day fingersticks with a regular insulin sliding scale as well as continue her nph insulin at 20 units q. a.m. and 20 units q. p.m. 7. for her anemia with her a very low mcv which is likely secondary to her history of thalassemia trait. a type and screen was sent and her epogen was continued. 8. gastrointestinal: she was continued on colace and p.r.n. bisacodyl. her tube feeds were started. stools were guaiac, however, she had not had a stool. a ggt was checked because of her elevated alkaline phosphatase and this was also found to be elevated at a level of 68. 9. history of pericardial effusion status post window. this is another reason that we wanted to check a transthoracic echocardiogram. she had cardiomegaly on chest x-ray, however, there is no evidence of tamponade on her ekg. 10. fluids, electrolytes and nutrition: most of this was already discussed in the renal section. she was gently hydrated with normal saline 60 cc per hour overnight. the bun and creatinine appear to have maybe remained stable now. she had hypoalbuminemia and nutrition was consulted. we are continuing her calcium carbonate. we are also continuing free water boluses 125 cc per hour q. eight hours per the g-tube. however, if her sodium continues to decrease, then these can be stopped. her electrolytes probably need to be followed twice a day. 11. ventilator: she is currently on assist control 500 x 12, 5 of peep/40% saturation and is saturating well. there is no current reason to change her ventilation settings at this time. 12. prophylaxis: she is on subcutaneous heparin and protonix. 13. tubes, lines and drains: she arrived to the floor with one very small peripheral intravenous in her left finger. a consultation in the a.m. was put in for a stat picc line. the interventional team had assessed her at the bedside and at the time of this dictation, it appears that she will not be undergoing picc placement, but rather will attempt to place some sort of central line. it is unknown exactly how we are going to obtain this access at the point of this dictation. a foley catheter is in place. 14. full code. condition at discharge: fair. discharge status: it was recommended by dermatology that she would benefit from transfer to a burn unit. at this time, she has been accepted to go to the [**hospital6 **] burn unit. of note, it was decided not to start her on intravenous igg at this point. discharge medications: 1. amlodipine 10 mg q. day p.o., recently began on [**11-22**], after the rash had appeared, but has been held today. 2. hydralazine 100 mg four times a day; she has been on this medication for a while. please note that the vent-core sheets report that she began this medicine on [**11-21**], however, this was only a renewal according to dr. [**last name (stitle) **]. 3. lasix 40 mg twice a day. 4. nph 20 units twice a day. 5. h2o 125 cc three times a day. 6. benadryl 25 mg q. eight hours. 7. subcutaneous heparin 5000 twice a day. 8. prednisone 5 mg q. day. 9. protein soy supplement, two scoops in the feeding tube q. eight hours. 10. nepro 3/4 strength tube feeds 35 cc per hour. 11. clonidine 0.3 three times a day. 12. bisacodyl 10 mg q. day p.r.n. 13. regular insulin sliding scale with humulin. 14. lopressor 100 mg four times a day. 15. labetalol 200 mg four times a day. 16. isosorbide dinitrate 40 mg q. eight hours. 17. sublingual nitroglycerin p.r.n. 18. protonix 40 q. day. 19. epogen 40,000 units subcutaneously weekly. 20. brimonidine 0.2% solution, one drop bilaterally q. eight hours. 21. eiazdolamide one drop solution to each eye three times a day. 22. ativan 1 mg q. eight hours. 23. calcium carbonate 500 mg q. eight hours. 24. ipratropium and albuterol mdi four puffs q. four hours p.r.n. discharge diagnoses: 1. acute renal failure. 2. rash most consistent with toxic epidermal necrolysis (ten). 3. severe hypertension on several anti-hypertensive. 4. chronic obstructive pulmonary disease. 5. status post tracheostomy [**7-17**] and peg [**7-28**]. 6. status post pericardial effusion with window placement on [**7-9**]. 7. history of bilateral pleural effusion. 8. history of breast cancer as above. 9. type 2 diabetes mellitus. [**name6 (md) **] [**name8 (md) **], m.d. [**md number(1) 968**] dictated by:[**name8 (md) 210**] medquist36 d: [**2177-11-26**] 13:53 t: [**2177-11-26**] 15:00 job#: [**job number 103106**]",1
155,"admission date: [**2179-1-17**] discharge date: [**2179-1-28**] date of birth: [**2111-4-12**] sex: m service: medicine allergies: heparin flush attending:[**first name3 (lf) 2736**] chief complaint: hypotension found at rehab major surgical or invasive procedure: right internal jugular central line was placed history of present illness: 67 yo male with cad s/p cabg, chf ef 20%, htn, dm2, h/o uti, h/o cons bacteremia, most recently admitted for ischemic bowel s/p small bowel resection and anastomosis, now admitted for hypotension and low grade temps. patient had been at [**hospital1 **] doing fairly well, when this am his vitals were checked and his sbps were in the 70s. patient tends to run in the high 90s/low 100s. he was given a 250 cc bolus, with improvement to the 80s, and then transferred to [**hospital1 18**] ed for further evaluation. . in the ed, initial vs: 100.4, 64, 93/58, 15, 99%2l. he had an initial cxr which was not too remarkable, but given his persistent abdominal pain and his recent surgery, patient had a ct torso which revealed rll atelectasis, but no acute pathology in the abdomen/pelvis. he was given vancomycin/zosyn to cover for hap as well as any abdominal pathology. ua was negative. lfts were wnl. patient was given 1.5l ivfs in the ed, and given his significant anemia, he was ordered for 2 units prbcs which were not given until after transfer. while he was in the ed, he was again hypotensive to the low 80s, therefore a rij was placed, and the patient was started on levophed to maintain maps. surgery was consulted in the ed, felt there was no acute surgical issue. an ecg showed no acute ischemic changes, trop was 0.03 and he was given asa pr. he was then transferred to the micu for further evaluation. his vitals prior to transfer were 63, 93/50, 15, 100%2l. past medical history: cad s/p cabgx3 [**2168**] - h/o vf arrest [**6-30**] s/p icd placement; required explantation for mrsa pocket infection with reimplantation [**10-31**], s/p lead removal [**4-2**] - mechanical [**last name (lf) 1291**], [**first name3 (lf) **]. [**male first name (un) 1525**], [**2168**] - ascending aorta repair c graft [**4-/2169**] - chf (ef 20% per tte [**2178-8-19**]) - high grade cons bacteremia in [**2-2**] c/b high grade cons, vre bactermia while on vancomycin [**3-2**], s/p 4 weeks daptomycin and explantation of icd leads - pseudomonas uti [**6-2**] s/p cefepime x 14 days, now pseudomonas uti [**8-2**] s/p meropenem x 14 days - r lateral foot ulcer s/p debridement s/p zosyn x 14 days - dm2 c/b neuropathy - hep c (dx [**4-2**], 2.38 million iu/ml. seen by hepatology, [**2178-7-30**] note emphasizes deferring ifn/ribavirin tx for now given infections, etc.) - htn - hlp - pvd s/p l bka [**7-27**] - hypothyroidism - h/o opiate dependence, ?benzo dependence - acute on chronic sdh, [**8-30**] - h/o r scapula fx - h/o mrsa elbow bursitis, [**5-1**] - h/o closed bimalleolar fx s/p repair, removal of hardware [**6-26**] social history: lives in [**location (un) **], though has been in rehab for much of the past few months. former cab driver. social history is significant for the current tobacco use of 40 pack years. there is no history of alcohol abuse or recreational drug use. lives with common-law wife of 35 years who is a home health aid. family history: no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. physical exam: vs: t: 96.7 hr: 87 bp: 108/55 rr: 16 02 sats: 94% ra gen: caucasian male in nad heent: moist mucus membranes, anicteric neck: jvp cv:: s1, s2 2/6 sem, mechanical s2, regular rhythm resp: bibasilar crackles abd: +bs, soft, nt, obese ext: l bka, r c with chronic venous stasis2+ edema to knees. pertinent results: echo: the left atrium is moderately dilated. the estimated right atrial pressure is 0-5 mmhg. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is moderately dilated with moderate to severe global hypokinesis (lvef = 25 %). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. a bileaflet aortic valve prosthesis is present. the aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. trace aortic regurgitation is seen. [the amount of regurgitation present is normal for this prosthetic aortic valve.] the mitral valve leaflets are structurally normal. moderate (2+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of [**2178-12-28**], the left ventricular cavity is slightly smaller and global lvef is slightly improved. moderate pulmonary artery systolic hypertension is now identified. increased pcwp. clinical implications: cxr [**1-17**]: comparison is made to the prior study from [**2179-1-17**] at 8:25 hours. there is no change in the appearance of the chest. there is continued bibasilar atelectasis, elevation of the right hemidiaphragm, small right pleural effusion. new right ij catheter terminates in superior vena cava. right picc is unchanged. the patient is status post sternotomy. ct abdomen: [**1-17**] impression: 1. fluid obstructing the right lower lobe bronchus, resulting in lobar atelectasis of the right lower lobe. this may be related to aspiration. 2. moderate right pleural effusion and small left pleural effusion. 3. patent small bowel anastomosis, without obstruction, fluid collection, or other abnormality. 4. cholelithiasis without cholecystitis. 5. no evidence of new mesenteric ischemia. 6. diverticulosis without diverticulitis. 7. extensive atherosclerotic disease brief hospital course: 67m with cad s/p cabg, systolic chf ef 20%, mechanical [**month/year (2) 1291**] for aortic insufficiency, s/p bental/chabral/aaa repair, dm2, htn, h/o uti, h/o cons bacteremia, recently admitted for ischemic bowel s/p small bowel resection and primary anastomosis admitted with hypotension and low grade temps. . # sirs/sepsis: he was noted to have low grade temperature, hypotension with white count of 4. in the ed a central line was placed and sepsis protocal initiated. the source of infection was not immediately clear - ua negative, cxr wtih rll atelectasis vs. aspiration, ct abdomen without definite pathology, c. diff negative, and no thrombus on echo. he was started on levophed, received 2u prbcs and pancultured. he was started on broad coverage antibiotics including vancomycin and zosyn for possible aspiration pneumonia and/or abdominal source and admitted to the micu. he did well in the micu; was quickly weaned off of pressors and subsequently required diuresis on the floor. he had a tte which did not show evidence of endocarditis. he also received daily ekg's to evaluate for possible pr prolongation which could indicate endocarditis. he completed a 10 day course of zosyn and vancomycin. . # chronic systolic chf (ef 20%). the diuretics, carvedilol, and ace-i were held on admission in the setting of hypotension. an echo was done that showeed no change in global systolic function compared to prior. his hospital course was complicated by flash pulmonary edema in the setting of htn during a bowel movement requiring intubation. he was extubated the following day. he received diuresis initially with lasix drip and then subsequently was started on torsemide po and spironolactone to goal net negative fluid balance of 0.5-1l per day. he was still felt to be volume overloaded at discharge so plan to continue diuresis to net negative 500-1000cc/day with fliud restriction of 1.5l/day. . #heparin induced thrombocytopenia: per dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 8651**], at [**hospital 1319**] rehab, patient has positive hit antibody test (unclear optical density). we re-sent heparin dependent antibodies, which were negative, although after discussion with the blood bank there was still concern for re-introducting the patient to heparin. an adverse reaction was added to the patient's electronic chart pending the completion of these studies. patient should not be given heparin, including heparin flushes, until these tests return. . # anemia: patient had initial hct drop to 22 in setting of supratherapeutic inr; received transfusion of 2 u prbcs and bumped appropriately. he was guaiac negative in ed. ct without any evidence of acute bleed. dic and hemolysis labs did not show any abnormalities. coumadin was held and no ffp given because patients mechanical valve. coumadin was reinitiated to maintain his inr in the therapeutic range, his inr was monitored and he had no further evidence of bleeding. . # mechical [**hospital 1291**]: patient on warfarin; inr goal 2.5-3.5.he arrived with supratherapeutic inr so warfarin held. his warfarin was subseqeuntly restarted at home dose with therapeutic inr maintained between 2-2.5. . # abdominal pain: patient has chronic abd pain since surgery; had ischemic bowel and is s/p anastamosis. ct torso without any acute pathology noted. lfts are wnl. patient reports that current pain is consistent with pain he has been having since discharge. surgery was aware and saw patient without any new recommendations made. c.diff was negative. . # htn: during his hospitalization he was hypertensive to the 170s, experiencing flash pulmonary edema with subsequent transfer to the icu. he has at this point had several episodes of flash pulmonary edema raising the question of why his htn is difficult to control, and why he flashes so easily. renal artery stenosis is a possible etiology of hypertension in the setting of repeated flash pulmonary edema, however patient had aortogram in [**2169**] which showed patent renal arteries. repeat imaging may be considered as an outpatient. he became hypotensive in the setting of diuresis in the icu and his antihypertensives were initially held, and restarted judiciously, and he remained normotensive. . #diabetes: blood sugar control was maintained on an insulin sliding scale with glargine for basal coverage and humalog based on finger-sticks three times a day. . medications on admission: acetaminophen 325-650 mg q6h prn albuterol nebs q6h prn amiodarone 200 mg daily amitryptiline 10 mg qhs atorvastatin 40 mg qhs captopril 12.5 mg tid carvedilol 12.5 mg [**hospital1 **] fondaparniux 7.5 mg sq daily colace 100 mg tid gabapentin 400 mg tid lantus 50 units qhs humalog iss atrovent nebs q6h prn keppra 500 mg qhs ativan 0.5-1mg q6-8h prn anxiety metolazone 5 mg [**hospital1 **] zofran 4 mg q8h prn oxycodone 5-10 mg q6h prn pantoprazole 40 mg daily senna 1 tab [**hospital1 **] prn spironolactone 25 mg daily torsemide 30 mg [**hospital1 **] warfarin 2.5 mg daily mvi daily discharge medications: 1. acetaminophen 325 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain/fever. 2. ipratropium bromide 0.02 % solution sig: one (1) inhalation inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 3. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation inhalation q6h (every 6 hours) as needed for wheezing. 4. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 5. amitriptyline 10 mg tablet sig: one (1) tablet po hs (at bedtime). 6. atorvastatin 40 mg tablet sig: one (1) tablet po hs (at bedtime). 7. levetiracetam 500 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 8. multivitamin,tx-minerals tablet sig: one (1) tablet po daily (daily). 9. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for cough. 10. torsemide 20 mg tablet sig: three (3) tablet po bid (2 times a day). 11. warfarin 2 mg tablet sig: one (1) tablet po once daily at 4 pm. 12. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). 13. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed for pain. 14. metoprolol succinate 25 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po once a day. 15. lisinopril 5 mg tablet sig: one (1) tablet po once a day: would increase dosage if hypertensive. 16. ranitidine hcl 150 mg tablet sig: one (1) tablet po twice a day. 17. outpatient lab work inr check twice weekly for goal inr of [**1-26**].5 18. nitroglycerin 0.4 mg tablet, sublingual sig: one (1) sublingual 1 tablet every 5 minutes, up to 3, if pain persists call 911 as needed for chest pain. 19. aspirin 81 mg tablet sig: one (1) tablet po once a day. 20. senna 8.6 mg tablet sig: 1-2 tablets po twice a day. 21. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 22. insulin glargine 100 unit/ml solution sig: sixty five (65) units subcutaneous once a day: 8pm. 23. insulin lispro 100 unit/ml solution sig: use before meals to prevent elvated blood sugar three times a day subcutaneous once a day. 24. gabapentin 300 mg capsule sig: one (1) capsule po three times a day. 25. outpatient lab work chem-10 at least three times a week 26. mepilex ag 6 x 6 bandage sig: one (1) topical every seventy-two (72) hours: to abdominal wound with gauze dressing. 27. lorazepam 0.5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for anxiety. 28. miralax 17 gram powder in packet sig: one (1) po once a day as needed for constipation. 29. fluid restric to <1.5l /day 30. lactulose 10 gram/15 ml syrup sig: thirty (30) ml po tid (3 times a day): hold if >3 bowel movements per day . discharge disposition: extended care facility: [**hospital3 7**] & rehab center - [**hospital1 8**] discharge diagnosis: primary presumed pneumonia pulmonary edema . secondary acute congestive heart failure exacerbation discharge condition: non ambulatory (below the knee amputation on left) mental status (alert and oriented to person place and time) discharge instructions: you were admitted to the hospital because you were having difficulty breathing. your cxr here suggested a pneumonia and you were treated with antibiotics. while you were here you became very hypertensive and experienced flash pulmonary edema. you went to the intensive care unit. you received diuretics to remove the extra fluid and you were transferred back to the regular floor. there you were started on oral diuretics for a goal negative fluid balance. . the following changes were made to your medications. 1. increase torsemide to 60mg by mouth twice a day 2. increase sprinolactone to 25mg by mouth once a day 3. increase metoprolol succinate to 25mg by mouth once a day 4. start taking lisinopril 5mg by mouth once a day 5. stop taking captopril 6. start taking amitripyline by mouth for peripheral neuropathy 7. take your stool softners to prevent constipation weigh yourself every morning, [**name8 (md) 138**] md if weight goes up more than 3 lbs. followup instructions: 1. provider: [**first name11 (name pattern1) **] [**last name (namepattern1) 544**], m.d. date/time:[**2179-1-29**] 11:50 2. provider: [**first name11 (name pattern1) **] [**last name (namepattern4) 1244**], md phone:[**telephone/fax (1) 1237**] date/time:[**2179-2-23**] 10:15 3. provider: [**first name8 (namepattern2) **] [**last name (namepattern1) **], md phone: [**telephone/fax (1) 62**] date/time: [**2179-3-19**] 2:20",1
156,"name: [**known lastname 684**], [**known firstname 6908**] unit no: [**numeric identifier 6909**] admission date: [**2114-9-7**] discharge date: [**2114-10-10**] date of birth: [**2091-4-26**] sex: m service: bone marrow transplant addendum: please refer to discharge summary dated [**2114-9-24**] for the details of admission up until [**2114-9-24**]. the following is the summary of the [**hospital 1325**] hospital course from [**2114-9-24**] until the date of discharge, [**2114-10-10**]. 1. hematology/pulmonary: on [**2114-9-24**], the patient was day number 11 status post matched unrelated donor bone marrow transplant for cml. at this time in his hospital course the patient began to demonstrate signs of engraftment, including an increased white blood cell count. he had accompanying third spacing of fluids, initially manifested by swelling of the face and extremities. on day number 14, status post transplant, the patient became increasingly tachypneic and hypoxemic and a chest x-ray revealed pulmonary edema. the patient was transferred to the icu and intubated for hypoxemia. the patient was successfully diuresed with lasix, and then began to autodiurese. while in the icu, the patient received high-dose steroids for possible diffuse alveolar hemorrhage, as well as out of the intensive care unit on cyclosporin for potential graft-versus-host disease. a bronchoalveolar lavage was performed which revealed clear, slightly pink fluid. the patient received two echocardiograms which were negative for evidence of heart failure. the patient was successfully extubated on day number 18 status post bone marrow transplant and transferred back to the bone marrow transplant unit on day number 19. his cell counts of all three lineages continued to increase to levels of white count 6.4, hematocrit 30.4, and platelet count 90,000 on the day prior to discharge. 2. infectious disease: as of day number 11 status post transplant, the patient was continuing to spike fevers of greater than 102 degrees. the differential diagnosis for these fevers was felt to include graft-versus-host disease as well as infection. on day number 11, the patient's antibiotic regimen included cefepime, ciprofloxacin, metronidazole, and voriconazole. on day number 11, the patient's ciprofloxacin was discontinued as the patient had a rash and was noted to have a prior allergic reaction to fluoroquinolones. on day number 13 status post transplant, the cefepime and metronidazole were discontinued as the patient's blood cultures and nasopharyngeal swabs did not demonstrate any evidence of infection. on day number 14, aztreonam was initiated as the patient had a chest x-ray demonstrating interstitial infiltrates. upon transfer to the intensive care unit, this coverage was expanded to include linezolid. the linezolid was discontinued on day number 17, and aztreonam on day number 18. after transfer back to the bone marrow transplant unit, the patient remained afebrile off of these antibiotics. voriconazole was discontinued on day number 20. bal washings were negative for bacteria, viruses, and fungi. the patient had further negative blood and urine cultures and had a clostridium difficile toxin which returned negative. the patient was discharged off of all antimicrobial medications. 3. renal: as of day number 11, the patient had sustained an increase in his creatinine to 1.6. the differential diagnosis in this rise was felt to include third spacing of fluids causing intravascular volume depletion (the patient had a fena of less than 1%), as well as an adverse reaction to liposomal amphotericin b. the patient's creatinine reached a maximal value of 1.8, and then proceeded to correct after the patient began diuresing. at the time of transfer out of the intensive care unit, the patient's creatinine was 0.9 and it remained in this vicinity during the duration of the admission. 4. gastrointestinal/nutrition: as of day number 11 the patient had poor p.o. intake secondary to mucositis and lack of appetite. oral intake was encouraged, initially with a diet of soft solids and boost. this diet was advanced after the patient returned from the intensive care unit to the point where the patient was tolerating full solids. he had a period of diarrhea which was resolved at the time of discharge. discharge diagnosis: cml, status post mud bone marrow transplant. discharge condition: fair. discharge status: to a medical center apartment, with q. day follow-up appointments. discharge medications: 1. neoral 200 mg p.o. b.i.d. 2. multivitamin. 3. folate. 4. glutamine. [**first name11 (name pattern1) **] [**initial (namepattern1) **] [**last name (namepattern1) **], m.d. dictated by:[**last name (namepattern1) 5970**] medquist36 d: [**2115-3-12**] 04:05 t: [**2115-3-12**] 17:47 job#: [**job number 6910**]",1
157,"name: [**last name (lf) 447**],[**known firstname 9070**] e unit no: [**numeric identifier 9071**] admission date: [**2107-11-21**] discharge date: [**2107-12-9**] date of birth: [**2087-9-18**] sex: f service: medicine allergies: amoxicillin / penicillins / neurontin / erythromycin / iv dye, iodine containing / optiray 350 / compazine attending:[**first name3 (lf) 758**] addendum: please see above for follow-up instructions with dr [**last name (stitle) 7492**] in oral maxillofacial surgery. discharge disposition: home discharge diagnosis: primary: 1. anaphylactoid reaction 2. epinephrine overdose. 3. acute lung injury. 4. acute cardiac injury. 5. acute dystonic reaction and trismus (lock jaw) 6. left hip/back pain, possibly due to a herniated disc 7. multiple sclerosis flare. discharge condition: heart and lung exams have returned to [**location 1867**]. face, jaw, and hand spasms, resulting from an adverse reaction to compazine, have resolved. you are being discharged in stable condition, but need close follow-up as an outpatient to ensure full recovery from your complex hospital course. discharge instructions: you were evaluated in the emergency department for left-sided flank pain. you had an abdominal ct scan to evaluate this pain, and had a severe allergic ""anaphylactoid"" reaction to the intravenous contrast used for the ct. you were given a high dose of epinephrine, as well as steroids, famotadine, benadryl, and intravenous fluids for treatment of this reaction. the severe allergic reaction and high dose of epinephrine resulted in injury to your heart and lungs. you were admitted and treated for this reaction in the intensive care unit for 2 days, and once stable, transferred to the medicine floor. you also developed a facial contortion and locked jaw (a dystonic reaction) in response to a medication you took for nausea, called compazine. this resolved initially with medications, except your jaw remained locked for 4 days. you recieved benadryl, benztropine (cogentin), and valium. higher doses of valium in addition to manual manipulation of your jaw was required to finally open the jaw. you developed symptoms of right foot inversion, right hand clumsiness, and right eye ""blurring"". an mri of your head was consistent with an active multiple sclerosis flare. you were treated with high-dose steroids for three days, with mild improvement. please remain at home for 1 week following discharge for further monitoring, given the recent complicated hospital course involving anaphylactic reaction, myocardial injury, acute lung injury, and acute dystonic reaction. your back pain is likely from a bulging disc in your spine. you can treat this with pain medication for now, and if it does not resolve in [**1-17**] weeks, please see your primary care physician to follow it up. please note that you are allergic to iv contrast, and had a dystonic reaction to compazine. these have been added to your allergy list. please return to the ed or call your primary care physician if you have symptoms similar to those you had in the ct scanner - throat tightness, ichiness, or any other concerning symptoms. please do the same if your jaw locks again. followup instructions: you have been scheduled for tysabri infusion at the pheresis unit on at monday [**2107-12-12**] at 2:15 pm. if you have any further questions, please contact your neurologist, dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 9072**], at ([**telephone/fax (1) 9073**] to schedule tysabri infusion. please f/u with your pcp in the next 2-3 weeks regarding the back pain. please call dr [**last name (stitle) 7492**] (oral maxillofacial surgery) to arrange an appointment for further evaluation of your jaw. [**first name11 (name pattern1) 27**] [**last name (namepattern1) 28**] md, [**md number(3) 765**] completed by:[**0-0-0**]",1
158,"name: [**known lastname 15553**],[**known firstname 17668**] unit no: [**numeric identifier 17669**] admission date: [**2123-6-16**] discharge date: [**2123-6-25**] date of birth: [**2024-5-6**] sex: f service: medicine allergies: levaquin attending:[**first name3 (lf) 2544**] addendum: due to concern of the isordil dropping the patient's blood pressure in the setting of as, this was discontinued at discharge. in addition, the lovenox will be continued but stopping this could be considered at the next follow up appointment. these issues were discussed with the patient's daughter, [**name (ni) **]. discharge medications: 1. prednisone 1 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 2. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 3. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 5. enoxaparin sodium 40 mg/0.4ml syringe sig: one (1) injection subcutaneous once a day. disp:*60 injection* refills:*2* 7. docusate sodium 150 mg/15 ml liquid sig: one hundred (100) mg po bid (2 times a day). disp:*1 bottle* refills:*4* 8. furosemide 40 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 9. albuterol sulfate 0.083 % solution sig: one (1) nebulizer inhalation every six (6) hours as needed for shortness of breath or wheezing: and give extra dose of lasix for unresponsive shortness of breath. disp:*30 nebulizers* refills:*2* 10. atrovent 0.02 % solution sig: one (1) nebulizer inhalation every 6-8 hours as needed for shortness of breath or wheezing: and give extra dose of lasix for unresponsive shortness of breath. disp:*30 nebulizers* refills:*2* 11. metoprolol succinate 100 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily). 12. adverse reaction no opiates or benzos! discharge disposition: extended care facility: [**hospital3 163**] - [**location (un) 164**] [**first name11 (name pattern1) **] [**last name (namepattern4) 2545**] md [**md number(2) 2546**] completed by:[**2123-6-25**]",1
159,"anemia, acute, secondary to blood loss (hemorrhage, bleeding) assessment: drainage from right lateral hip and thigh incision being monitored. continuous hemodynamic monitoring in progress. right ij triple lumen central line insitu with cvp monitoring. assess right thigh for extreme distention, thigh circumference measured for comparison, and distal pulses being assessed. trending lab valve monitoring with necessary interventions. action: right ij central line placed this am to facilitate monitoring of hemodynamic values. central line care per protocol being maintained.vss being done q1hr. peripheral pulse assessment done q4hr as needed. consented blood transfusions given in relevance to lab values. pad beneath right leg assessed frequently and changed as needed. continue iv therapy as ordered. response: no adverse reaction noted to blood transfusion, vss remain within acceptable limits for patient. dressing to right thigh soiled but intact. two pads moderately saturated with bloody drainage changed over the last 12hours. peripheral pulses remain weak but palpable with regular rate and rhythm. urinary output has picked up and is within acceptable limits. plan: continue cvp monitoring and other hemodynamic assessments. ivf as ordered. monitor urinary output and follow lab trends with appropriate interventions as needed. electrolyte & fluid disorder, other assessment: monitor skin integrity, vss and cvp values. trend lab values comparatively. monitor mg, na, k, and ca levels. observe for abnormal ekg rhythms. action: given magnesium sulfate for mg of 1.4 also received calcium gluconate for ca of 7.7. response: some general non pitting edema noted. urinary output remains adequate. lab value have not deteriorated. plan: continue se diabetes mellitus (dm), type ii assessment: random blood sugar being monitored q4hr. observe for signs of hyper or hypoglycemia. action: blood sugar being managed per sliding scale oral hypoglycemic on hold response: blood sugars have been within normal limits and pt has shown no signs of hyper or hypoglycemia plan: continue q4hr. blood glucose level and manage per sliding scale orders.",0
160,"patient is a 76yr old female admitted with a presentation of light headedness and dark tary stool. she was advised by her oncology department to come to the ed for further evaluation. patient has h/o stage iib pancreatic ca and is currently receiving chemotherapy for same. .h/o gastrointestinal bleed, upper (melena, gi bleed, gib) assessment: patient has had no melena stool since admission to the unit. denies any nausea or emesis as well. now s/p endoscopy, results are still pending, however it has been communicated that the patient has an ulcer. action: patient is now s/p four units of prbcs and one unit of platelets. post endoscopy patient was started on sucralfate qid. can now have clear sips, no red fluid as tolerated. response: patient has tolerated transfusion without any adverse reactions. hct being checked q4hr and as needed. procedure was uneventful with patient responding appropriately. plan: continue to monitor lab values and treat as prescribed. monitor for obvious bleeding or melena stool. patient remains alert and oriented x3 moving all limbs well. can get up to the bedside commode with assistance, is a little unsteady and continues to c/o mild dizziness. breathing comfortably on room air with good air entry bilaterally. does have an significant cardiac murmur without any obvious tx at this time, this is not new for client. abdomen softly distended, patient does indicate that it feel more distended than ususal.",0
161,"patient is a 76yr old female admitted with a presentation of light headedness and dark tary stool. she was advised by her oncology department to come to the ed for further evaluation. patient has h/o stage iib pancreatic ca and is currently receiving chemotherapy for same. .h/o gastrointestinal bleed, upper (melena, gi bleed, gib) assessment: patient has had no melena stool since admission to the unit. denies any nausea or emesis as well. action: patient is now s/p four units of prbcs and one unit of platelets. response: patient has tolerated transfusion without any adverse reactions. hct being checked q4hr and as needed. plan: continue to monitor lab values and treat as prescribed. patient remains alert and oriented x3 moving all limbs well. can get up to the bedside commode with assistance, is a little unsteady and continues to c/o mild dizziness.",0
162,"44 yo f with pmh of htn, asthma and gi stromal tumor s/p multiple surgeries and prolonged hospitalizations here with lactic acidosis, oliguric renal failure and liver failure. respiratory failure, acute (not ards/[**doctor last name **]) assessment: remains intubated, vented and bolus sedated on ac 30% 500x20/5 abg : 7.36/25/130. rhonchi all throughout, no secreation w/suctioning. lactate at 14.8 action: mechanical ventilation, mouth care q4hr, vap prevention response: abg: 7.31/27/127 lactate 14.4 plan: monitor resp status, abg to eval , continue w/ventilation until acidosis resolves renal failure, acute (acute renal failure, arf) assessment: oliguric u/o 5-30cc/hr bun /creat - 20/2.8, general edema positive fluid balance, lactate 14.8 action: cvvhdf, meds at renal dose, renal follows response: bun/creat 16/2.3, lactate 14.4 plan: continue to monitor renal status, labs to eval, cvvhdf until rf and lactic acidosis resolves, f/u renal resc .h/o abdominal pain (including abdominal tenderness) assessment: abd firm distended, positive for hypoactive bs, ogt residuals 60-100cc, stool and gas in ostomy pouch. mid abd incision w/vac dressing at 125mmhg intact, elevated lft s, inr- 4.0, action: npo. bladder pressures 16-18, surgery managing, hepatology involved response: awaiting plan: monitor abd for s/s of acs/iah, f/u hep recs, cancer (malignant neoplasm), small bowel assessment: action: will start gleevec at a lower dose this am. onc follows response: awaiting plan: monitor for s/s of adverse reaction, cytokine storm, dnc recs.",1
163,"44 yo f with pmh of htn, asthma and gi stromal tumor s/p multiple surgeries and prolonged hospitalizations here with lactic acidosis, oliguric renal failure and liver failure. respiratory failure, acute (not ards/[**doctor last name **]) assessment: remains intubated, vented and bolus sedated on ac 30% 500x20/5 abg: 7.36/25/130. rhonchi all throughout, no secretion w/suctioning. lactate at 14.8 action: mechanical ventilation, mouth care q4hr, vap prevention response: abg: 7.31/27/127 lactate 14.4 plan: monitor resp status, abg to eval , continue w/ventilation until acidosis resolves renal failure, acute (acute renal failure, arf) assessment: oliguric u/o 5-30cc/hr bun /creat - 20/2.8, general edema positive fluid balance, lactate 14.8 action: cvvhdf, meds at renal dose, renal follows response: bun/creat 16/2.3, lactate 14.4 plan: continue to monitor renal status, labs to eval, cvvhdf until rf and lactic acidosis resolves, f/u renal recs .h/o abdominal pain (including abdominal tenderness) assessment: abd firm distended, positive for hypoactive bs, ogt residuals 60-100cc, stool and gas in ostomy pouch. mid abd incision w/vac dressing at 125mmhg intact, elevated lft s, inr- 4.0, action: npo. bladder pressures 16-18, surgery managing, hepatology involved response: awaiting plan: monitor abd for s/s of acs/iah, f/u hep recs, cancer (malignant neoplasm), small bowel assessment: action: will start gleevec at a lower dose this am. onc follows response: awaiting plan: monitor for s/s of adverse reaction, cytokine storm, onc recs. hepatic encephalopathy assessment: patient sedated on fentanyl/versed boluses. moves head and grimacing to pain stimuli. pupils at 2-3mm equal but sluggish to react. does not follow command. lft s still elevated, labile blood sugars, inr- 4.0 action: neuro checks, labs, hepatology consulting, meds at hepatic dosage. fs q2hr response: awaiting, brittle fs. d50/50 amp given for fs of 60 s, bicarb drip in d10 started in addition to tpn, dic panel sent plan: monitor patients status, labs to eval, f/u hep recs cardio: remains tachycardic at 110 s-130 s. st no ectopy noted. nbp at 100 s /50 s. peripheral pulses present. peripheral edema noted. cvp at [**10-7**] iv access: lt ij 3 lumen. lt piv 18g. lt a-line. rt hd cath social: family in to visit updated by rn. p.s wbc up to 20.4. afebrile however patient maintains temps of 98-99 on cvvhdf, blood cultures ordered.",1
164,"44 yo f with pmh of htn, asthma and gi stromal tumor s/p multiple surgeries and prolonged hospitalizations here with lactic acidosis, oliguric renal failure and liver failure. respiratory failure, acute (not ards/[**doctor last name **]) assessment: remains intubated, vented and bolus sedated on ac 30% 500x20/5 abg: 7.36/25/130. rhonchi all throughout, no secretion w/suctioning. lactate at 14.8 action: mechanical ventilation, mouth care q4hr, vap prevention response: abg: 7.31/27/127 lactate 14.4 plan: monitor resp status, abg to eval , continue w/ventilation until acidosis resolves renal failure, acute (acute renal failure, arf) assessment: oliguric u/o 5-30cc/hr bun /creat - 20/2.8, general edema, positive fluid balance, lactate 14.8 action: cvvhdf - no uf initially, if tolerates it ok for a few hours, then should be able to take volume off as tolerated, meds at renal dose, renal follows response: bun/creat 16/2.3, lactate 14.4 plan: continue to monitor renal status, labs to eval, cvvhdf until rf and lactic acidosis resolves, f/u renal recs .h/o abdominal pain (including abdominal tenderness) assessment: abd firm distended, positive for hypoactive bs, ogt residuals 60-100cc, stool and gas in ostomy pouch. mid abd incision w/vac dressing at 125mmhg intact, elevated lft s, inr- 4.0, action: npo. bladder pressures 16-18, surgery managing, hepatology involved response: awaiting plan: monitor abd for s/s of acs/iah, f/u hep recs, cancer (malignant neoplasm), small bowel assessment: action: will start gleevec at a lower dose this am. onc follows response: awaiting plan: monitor for s/s of adverse reaction, cytokine storm, onc recs. hepatic encephalopathy assessment: patient sedated on fentanyl/versed boluses. moves head and grimacing to pain stimuli. pupils at 2-3mm equal but sluggish to react. does not follow command. lft s still elevated, labile blood sugars, inr- 4.0 action: neuro checks, labs, hepatology consulting, meds at hepatic dosage. fs q2hr response: awaiting, brittle fs. d50/50 amp given for fs of 60 s, bicarb drip in d10 started in addition to tpn, dic panel sent plan: monitor patients status, labs to eval, f/u hep recs cardio: remains tachycardic at 110 s-130 s. st no ectopy noted. nbp at 100 s /50 s. peripheral pulses present. peripheral edema noted. cvp at [**10-7**] iv access: lt ij 3 lumen. lt piv 18g. lt a-line. rt hd cath social: family in to visit updated by rn. p.s wbc up to 20.4. afebrile however patient maintains temps of 98-99 on cvvhdf, blood cultures ordered.",1
165,"44 yo f with pmh of htn, asthma and gi stromal tumor s/p multiple surgeries and prolonged hospitalizations here with lactic acidosis, oliguric renal failure and liver failure. respiratory failure, acute (not ards/[**doctor last name **]) assessment: remains intubated, vented and bolus sedated on ac 30% 500x20/5 abg: 7.36/25/130. rhonchi all throughout, no secretion w/suctioning. lactate at 14.8 action: mechanical ventilation, mouth care q4hr, vap prevention response: abg: 7.31/27/127 lactate 14.4 plan: monitor resp status, abg to eval , continue w/ventilation until acidosis resolves renal failure, acute (acute renal failure, arf) assessment: oliguric u/o 5-30cc/hr bun /creat - 20/2.8, general edema, positive fluid balance, lactate 14.8 action: cvvhdf - no uf initially, if tolerates it ok for a few hours, then should be able to take volume off as tolerated, meds at renal dose, renal follows response: bun/creat 16/2.3, lactate 14.4 plan: continue to monitor renal status, labs to eval, cvvhdf until rf and lactic acidosis resolves, f/u renal recs .h/o abdominal pain (including abdominal tenderness) assessment: abd firm distended, positive for hypoactive bs, ogt residuals 60-100cc, stool and gas in ostomy pouch. mid abd incision w/vac dressing at 125mmhg intact, elevated lft s, inr- 4.0, action: npo. bladder pressures 16-18, surgery managing, hepatology involved response: awaiting plan: monitor abd for s/s of acs/iah, f/u hep recs, cancer (malignant neoplasm), small bowel assessment: action: will start gleevec at a lower dose this am. onc follows response: awaiting plan: monitor for s/s of adverse reaction, cytokine storm, f/u onc recs. hepatic encephalopathy assessment: patient sedated on fentanyl/versed boluses. moves head and grimacing to pain stimuli. pupils at 2-3mm equal but sluggish to react. does not follow command. lft s still elevated, labile blood sugars, inr- 4.0 action: neuro checks, labs, hepatology consulting, meds at hepatic dosage. fs q2hr response: awaiting, brittle fs. d50/50 amp given for fs of 60 s, bicarb drip in d10 started in addition to tpn, dic panel sent plan: monitor patients status, labs to eval, f/u hep recs cardio: remains tachycardic at 110 s-130 s. st no ectopy noted. nbp at 100 s /50 s. peripheral pulses present. peripheral edema noted. cvp at [**10-7**] iv access: lt ij 3 lumen. lt piv 18g. lt a-line. rt hd cath social: family in to visit updated by rn. p.s wbc up to 20.4. afebrile however patient maintains temps of 98-99 on cvvhdf, blood cultures ordered.",1
166,"44 yo f with pmh of htn, asthma and gi stromal tumor s/p multiple surgeries and prolonged hospitalizations here with lactic acidosis, oliguric renal failure and liver failure. respiratory failure, acute (not ards/[**doctor last name **]) assessment: remains intubated, vented and bolus sedated on ac 30% 500x20/5 abg: 7.36/25/130. rhonchi all throughout, no secretion w/suctioning. lactate at 14.8 action: mechanical ventilation, mouth care q4hr, vap prevention response: abg: 7.31/27/127 lactate 14.4 plan: monitor resp status, abg to eval , continue w/ventilation until acidosis resolves renal failure, acute (acute renal failure, arf) assessment: oliguric u/o 5-30cc/hr bun /creat - 20/2.8, general edema, positive fluid balance, lactate 14.8 action: cvvhdf - no uf initially, if tolerates it ok for a few hours, then should be able to take volume off as tolerated, meds at renal dose, renal follows response: bun/creat 16/2.3, lactate 14.4 plan: continue to monitor renal status, labs to eval, cvvhdf until rf and lactic acidosis resolves, f/u renal recs .h/o abdominal pain (including abdominal tenderness) assessment: abd firm distended, positive for hypoactive bs, ogt residuals 60-100cc, stool and gas in ostomy pouch. mid abd incision w/vac dressing at 125mmhg intact, elevated lft s, inr- 4.0, action: npo. bladder pressures 16-18, surgery managing, hepatology involved response: awaiting plan: monitor abd for s/s of acs/iah, f/u hep recs, cancer (malignant neoplasm), small bowel assessment: action: will start gleevec at a lower dose this am. onc follows response: awaiting plan: monitor for s/s of adverse reaction, cytokine storm, f/u onc recs. hepatic encephalopathy assessment: patient sedated on fentanyl/versed boluses. moves head and grimacing to pain stimuli. pupils at 2-3mm equal but sluggish to react. does not follow command. lft s still elevated, labile blood sugars, inr- 4.0 plt 84 action: neuro checks, labs, hepatology consulting, meds at hepatic dosage. fs q2hr response: awaiting, brittle fs. d50/50 amp given for fs of 60 s, bicarb drip in d10 started in addition to tpn, dic panel sent plan: monitor patients status, labs to eval, f/u hep recs cardio: remains tachycardic at 110 s-130 s. st no ectopy noted. nbp at 100 s /50 s. peripheral pulses present. peripheral edema noted. cvp at [**10-7**] iv access: lt ij 3 lumen. lt piv 18g. lt a-line. rt hd cath social: family in to visit updated by rn. p.s wbc up to 20.4. afebrile however patient maintains temps of 98-99 on cvvhdf, blood cultures ordered.",1
167,"44 yo f with pmh of htn, asthma and gi stromal tumor s/p multiple surgeries and prolonged hospitalizations here with lactic acidosis, oliguric renal failure and liver failure. respiratory failure, acute (not ards/[**doctor last name **]) assessment: remains intubated, vented and bolus sedated on ac 30% 500x20/5 abg: 7.36/25/130. rhonchi all throughout, no secretion w/suctioning. lactate at 14.8 action: mechanical ventilation, mouth care q4hr, vap prevention response: abg: 7.31/27/127 lactate 14.4 plan: monitor resp status, abg to eval , continue w/ventilation until acidosis resolves renal failure, acute (acute renal failure, arf) assessment: oliguric u/o 5-30cc/hr bun /creat - 20/2.8, general edema, positive fluid balance, lactate 14.8 action: cvvhdf - no uf initially, if tolerates it ok for a few hours, then should be able to take volume off as tolerated, meds at renal dose, renal follows response: bun/creat 16/2.3, lactate 14.4 plan: continue to monitor renal status, labs to eval, cvvhdf until rf and lactic acidosis resolves, f/u renal recs .h/o abdominal pain (including abdominal tenderness) assessment: abd firm distended, positive for hypoactive bs, ogt residuals 60-100cc, stool and gas in ostomy pouch. mid abd incision w/vac dressing at 125mmhg intact, elevated lft s, inr- 4.0, action: npo. bladder pressures 16-18, surgery managing, hepatology involved response: awaiting plan: monitor abd for s/s of acs/iah, f/u hep recs, cancer (malignant neoplasm), small bowel assessment: action: will start gleevec at a lower dose this am. onc follows response: awaiting plan: monitor for s/s of adverse reaction, cytokine storm, f/u onc recs. hepatic encephalopathy assessment: patient sedated on fentanyl/versed boluses. moves head and grimacing to pain stimuli. pupils at 2-3mm equal but sluggish to react. does not follow command. lft s still elevated, labile blood sugars, inr- 4.0 plt 84 ptt-104.9 action: neuro checks, labs, hepatology consulting, meds at hepatic dosage. fs q2hr response: awaiting, brittle fs. d50/50 amp given for fs of 60 s, bicarb drip in d10 started in addition to tpn, dic panel sent plan: monitor patients status, labs to eval, f/u hep recs cardio: remains tachycardic at 110 s-130 s. st no ectopy noted. nbp at 100 s /50 s. peripheral pulses present. peripheral edema noted. cvp at [**10-7**] iv access: lt ij 3 lumen. lt piv 18g. lt a-line. rt hd cath social: family in to visit updated by rn. p.s wbc up to 20.4. afebrile however patient maintains temps of 98-99 on cvvhdf, blood/urine cultures ordered.",1
168,"44 yo f with pmh of htn, asthma and gi stromal tumor s/p multiple surgeries and prolonged hospitalizations here with lactic acidosis, oliguric renal failure and liver failure. respiratory failure, acute (not ards/[**doctor last name **]) assessment: remains intubated, vented and bolus sedated on ac 30% 500x20/5 abg: 7.36/25/130. rhonchi all throughout, no secretion w/suctioning. lactate at 14.8 action: mechanical ventilation, mouth care q4hr, vap prevention response: abg: 7.31/27/127 lactate 14.4 plan: monitor resp status, abg to eval , continue w/ventilation until acidosis resolves renal failure, acute (acute renal failure, arf) assessment: oliguric u/o 5-30cc/hr bun /creat - 20/2.8, general edema, positive fluid balance, lactate 14.8 action: cvvhdf - no uf initially, if tolerates it ok for a few hours, then should be able to take volume off as tolerated, meds at renal dose, renal follows response: bun/creat 16/2.3, lactate 14.4 plan: continue to monitor renal status, labs to eval, cvvhdf until rf and lactic acidosis resolves, f/u renal recs .h/o abdominal pain (including abdominal tenderness) assessment: abd firm distended, positive for hypoactive bs, ogt residuals 60-100cc, stool and gas in ostomy pouch. mid abd incision w/vac dressing at 125mmhg intact, elevated lft s, inr- 4.0, action: npo. bladder pressures 16-18, surgery managing, hepatology involved response: awaiting plan: monitor abd for s/s of acs/iah, f/u hep recs, cancer (malignant neoplasm), small bowel assessment: action: will start gleevec at a lower dose this am. onc follows response: awaiting plan: monitor for s/s of adverse reaction, cytokine storm, f/u onc recs. hepatic encephalopathy assessment: patient sedated on fentanyl/versed boluses. moves head and grimacing to pain stimuli. pupils at 2-3mm equal but sluggish to react. does not follow command. lft s still elevated, labile blood sugars, inr- 4.0 plt 84 ptt-104.9 action: neuro checks, labs, hepatology consulting, meds at hepatic dosage. fs q2hr response: awaiting, brittle fs. d50/50 amp given for fs of 60 s, bicarb drip in d10 started in addition to tpn, dic panel sent plan: monitor patients status, labs to eval, f/u hep recs cardio: remains tachycardic at 110 s-130 s. st no ectopy noted. nbp at 100 s /50 s. peripheral pulses present. peripheral edema noted. cvp at [**10-7**] iv access: lt ij 3 lumen. lt piv 18g. lt a-line. rt hd cath social: family in to visit updated by rn. p.s wbc up to 20.4. afebrile however patient maintains temps of 98-99 on cvvhdf, blood/urine cultures ordered.",1
169,"patient is a [**age over 90 323**]yr old female who is a resident at [**location (un) 109**] house. presented to the ew after nursing staff at the facility noted that she was having hemotchezia. on admission to the ew patient s hct was 20 from previous 28; she is now s/p two units of prbcs. patient after receiving gastrografin for the ct abdomen in the ed was reported to have become aggressive and was given haldol 2mg. she does have an h/o dementia and is calm and cooperative on admission. no family member present on admission and patient is a poor historian. patient s code status dnr/dni gastrointestinal bleed, lower (hematochezia, brbpr, gi bleed, gib) assessment: hct on admission to the ed was 20. at nursing facility patient reported to be having hematochezia x 2days, got progressively worse last pm and was sent to the ed. action: patient now s/p 2 units of prbcs. repeat hct between units 24.6. other lab results unremarkable. ct of the abdomen done in the ed response: no adverse reaction with transfusions. patient remains afebrile. had one episode of what appear to be hematochezia shortly after admission. all stools for guiac. report from the ed nurse indicated that ct of the abdomen was positive for diverticulosis and right peritoneal cysts. plan: continue to follow lab trends and treat anemia as recommended. cns: patient is alert and pleasantly confused, following commands consistently and mae. however this morning patient was not willing to be touched or have her temperature taken. she has been reported to become physical. bed alarm has been activated. cvs: sinus rhythm on the monitor with rare pvcs. sbp 112-169 and dbp 49-97. resp: breathing spontaneously on o2 via nc at 2l/min. with good air entry bilaterally no added sounds noted. on several occasions last night patient desaturated to the 80s for few seconds. during these episodes noted that patient had very shallow respirations 8-16bpm. physician informed and no new orders. gi: abdomen soft non tender with present bowel sounds present in all four quads. ct of the abdomen done. no more bm since 0100. gu: urinary catheter draining adequate amount of yellow colored urine. integ: left lateral knee skin tear noted on admission. area cleansed with normal saline and dressed using adaptic. multiple areas of ecchymosis to upper extremities noted with skin intact.",0
170,"patient is a 76yr old female admitted with a presentation of light headedness and dark tary stool. she was advised by her oncology department to come to the ed for further evaluation. patient has h/o stage iib pancreatic ca and is currently receiving chemotherapy for same. .h/o gastrointestinal bleed, upper (melena, gi bleed, gib) assessment: patient has had no melena stool since admission to the unit. denies any nausea or emesis as well. now s/p endoscopy, results are still pending, however it has been communicated that the patient has an ulcer. action: patient is now s/p four units of prbcs and one unit of platelets. post endoscopy patient was started on sucralfate qid. can now have clear sips, no red fluid as tolerated. response: patient has tolerated transfusion without any adverse reactions. hct being checked q4hr and as needed. procedure was uneventful with patient responding appropriately. plan: continue to monitor lab values and treat as prescribed. monitor for obvious bleeding or melena stool. patient remains alert and oriented x3 moving all limbs well. can get up to the bedside commode with assistance, is a little unsteady and continues to c/o mild dizziness. breathing comfortably on room air with good air entry bilaterally. does have an significant cardiac murmur without any obvious tx at this time, this is not new for client. abdomen softly distended, patient does indicate that it feel more distended than ususal.",0
171,"chief complaint: scse 24 hour events: - more activity on eeg, so increased versed back to 1mg gtt - healthcare proxy came in, discussed current situation with family, upset about current situation, would like to discuss with neurology - ? starting phenobarbital, patient with previous adverse reaction - tolerated brief trial of pressure support during the day - 40mg iv lasix for net out -40cc allergies: no known drug allergies last dose of antibiotics: cefipime - [**2115-4-23**] 07:40 pm infusions: midazolam (versed) - 1 mg/hour other icu medications: ranitidine (prophylaxis) - [**2115-4-24**] 09:00 am furosemide (lasix) - [**2115-4-24**] 10:41 pm heparin sodium (prophylaxis) - [**2115-4-25**] 12:00 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2115-4-25**] 07:55 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.2 c (99 tcurrent: 37.1 c (98.7 hr: 83 (73 - 83) bpm bp: 117/55(71) {99/49(64) - 134/77(92)} mmhg rr: 17 (14 - 22) insp/min spo2: 94% heart rhythm: sr (sinus rhythm) wgt (current): 73.5 kg (admission): 69 kg height: 66 inch total in: 2,298 ml 584 ml po: tf: 1,040 ml 300 ml ivf: 768 ml 185 ml blood products: total out: 1,600 ml 1,260 ml urine: 1,600 ml 1,260 ml ng: stool: drains: balance: 698 ml -676 ml respiratory support ventilator mode: cmv/assist/autoflow vt (set): 400 (400 - 400) ml vt (spontaneous): 477 (477 - 477) ml ps : 18 cmh2o rr (set): 12 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi: 199 pip: 22 cmh2o plateau: 17 cmh2o spo2: 94% abg: ///23/ ve: 6.9 l/min physical examination cardiovascular: (s1: normal), (s2: normal) peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) respiratory / chest: (breath sounds: crackles : ) abdominal: soft, non-tender, bowel sounds present extremities: right: 1+, left: 1+ skin: not assessed neurologic: responds to: unresponsive, movement: no spontaneous movement, tone: not assessed labs / radiology 226 k/ul 10.0 g/dl 94 mg/dl 0.8 mg/dl 23 meq/l 4.1 meq/l 36 mg/dl 107 meq/l 138 meq/l 32.0 % 13.1 k/ul [image002.jpg] [**2115-4-17**] 03:11 am [**2115-4-18**] 04:35 am [**2115-4-19**] 03:57 am [**2115-4-19**] 03:28 pm [**2115-4-20**] 03:10 am [**2115-4-21**] 04:52 am [**2115-4-22**] 04:23 am [**2115-4-23**] 05:06 am [**2115-4-24**] 03:37 am [**2115-4-25**] 03:37 am wbc 16.6 13.1 13.9 12.0 12.2 9.3 9.7 10.5 13.1 hct 30.3 34.0 28.6 30.0 31.1 31.1 30.0 30.5 32.0 plt 233 237 220 259 [**telephone/fax (2) 2568**]43 226 cr 0.8 0.9 0.8 0.9 0.8 0.7 0.8 0.9 0.8 tco2 28 glucose 116 117 102 113 98 85 97 107 94 other labs: pt / ptt / inr:14.1/32.1/1.2, ck / ckmb / troponin-t:241/12/0.39, albumin:2.8 g/dl, ldh:214 iu/l, ca++:8.6 mg/dl, mg++:2.0 mg/dl, po4:3.4 mg/dl assessment and plan 76 year old f with history a seizure disorder, chronic vent dependence transfered for hypoxia, and altered mental status. # pseudomonal pneumonia: moderate growth of pseudomonas on sputum cuilture from [**2037-4-14**], sensitive to cefepime. blood cultures with ngtd, and urine cultures negative. moderate afb on concentrated smear, non tb. have discontinued respiratory isolation. - completed cefepime course [**2115-4-23**] . # altered mental status: found to be in sub-clinical status epilepticus- unclear etiology. differential includes anoxic brain injury as patient had a pea prior to admission, toxic/metabolic encephalopathy from infection vs drugs (patient had mildly elevated dilantin level), or underlying seizure disorder.. mri negative for mass or infectious focus. she had a prior admission with similar altered mental status, however, eeg was negative at that time. she had an extensive neuro work up at that time which was largely unrevealing including lp, paraneoplastic labs which were negative, spep/upep, mri/mra brain, emg concerning for critical illness myopathy. - lp yesterday with negative gram stain and wbc 1, f/u culure - wean midazolam to 0.5mg/hr, keppra, phenytoin, follow daily phenytoin levels - if no increased eeg activity then decrease to 0.25mg/hr in 6 hours - final read of mri shows l posterior parietal small infarct which is likely not contributing to overall picture per neuro - follow up eeg read - neuro recs - sural nerve biopsy for neuropathy once stable - family not willing to consent as patient in satus . # respiratory failure - rsbi 146 - trial ps with ps 20/peep 5 to exercise lungs - daily rsbi with sbt if appropriate . #volume status: - patient gradually more overloaded over last week, cxr with pleural effusions, will diurese with lasix with goal -500 today - hold bp meds . # vomiting/regurgitation: had kub on admission showing stool in the [**last name (lf) 800**], [**first name3 (lf) **] have led to worsening residuals, vomiting and aspiration. s/p aggressive bowel regimen with bm at this time. regurgitation also improved at this time. will start senna and colace to assist with bm and avoid precipitating further aspiration. - aggressive bowel regimen, currently having bms . # anemia: baseline appears to be 27-28. stable . # hypertension: per history hypertension mostly a problem during breathing trials. was initially normotensive in the setting of dehydration and potential infection so bp meds held. restarted on some home meds with some improvement in blood pressure. - labetalol 800 tid, clonidine, hydralazine, lopressor all being held given hypotension with dilantin/propofol. would restart labetalol first w/ hydralazine next for afterload reduction. icu care nutrition: glycemic control: lines: picc line - [**2115-4-21**] 05:45 pm prophylaxis: dvt: boots, sq uf heparin stress ulcer: vap: hob elevation, mouth care, daily wake up, rsbi comments: communication: comments: code status: full code disposition:",1
172,"chief complaint: scse 24 hour events: - more activity on eeg, so increased versed back to 1mg gtt - healthcare proxy came in, discussed current situation with family, upset about current situation, would like to discuss with neurology - ? starting phenobarbital, patient with previous adverse reaction - tolerated brief trial of pressure support during the day - 40mg iv lasix for net out -40cc allergies: no known drug allergies last dose of antibiotics: cefipime - [**2115-4-23**] 07:40 pm infusions: midazolam (versed) - 1 mg/hour other icu medications: ranitidine (prophylaxis) - [**2115-4-24**] 09:00 am furosemide (lasix) - [**2115-4-24**] 10:41 pm heparin sodium (prophylaxis) - [**2115-4-25**] 12:00 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2115-4-25**] 07:55 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.2 c (99 tcurrent: 37.1 c (98.7 hr: 83 (73 - 83) bpm bp: 117/55(71) {99/49(64) - 134/77(92)} mmhg rr: 17 (14 - 22) insp/min spo2: 94% heart rhythm: sr (sinus rhythm) wgt (current): 73.5 kg (admission): 69 kg height: 66 inch total in: 2,298 ml 584 ml po: tf: 1,040 ml 300 ml ivf: 768 ml 185 ml blood products: total out: 1,600 ml 1,260 ml urine: 1,600 ml 1,260 ml ng: stool: drains: balance: 698 ml -676 ml respiratory support ventilator mode: cmv/assist/autoflow vt (set): 400 (400 - 400) ml vt (spontaneous): 477 (477 - 477) ml ps : 18 cmh2o rr (set): 12 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi: 199 pip: 22 cmh2o plateau: 17 cmh2o spo2: 94% abg: ///23/ ve: 6.9 l/min physical examination cardiovascular: (s1: normal), (s2: normal) peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) respiratory / chest: (breath sounds: crackles : ) abdominal: soft, non-tender, bowel sounds present extremities: right: 1+, left: 1+ skin: not assessed neurologic: responds to: unresponsive, movement: no spontaneous movement, tone: not assessed labs / radiology 226 k/ul 10.0 g/dl 94 mg/dl 0.8 mg/dl 23 meq/l 4.1 meq/l 36 mg/dl 107 meq/l 138 meq/l 32.0 % 13.1 k/ul [image002.jpg] [**2115-4-17**] 03:11 am [**2115-4-18**] 04:35 am [**2115-4-19**] 03:57 am [**2115-4-19**] 03:28 pm [**2115-4-20**] 03:10 am [**2115-4-21**] 04:52 am [**2115-4-22**] 04:23 am [**2115-4-23**] 05:06 am [**2115-4-24**] 03:37 am [**2115-4-25**] 03:37 am wbc 16.6 13.1 13.9 12.0 12.2 9.3 9.7 10.5 13.1 hct 30.3 34.0 28.6 30.0 31.1 31.1 30.0 30.5 32.0 plt 233 237 220 259 [**telephone/fax (2) 2568**]43 226 cr 0.8 0.9 0.8 0.9 0.8 0.7 0.8 0.9 0.8 tco2 28 glucose 116 117 102 113 98 85 97 107 94 other labs: pt / ptt / inr:14.1/32.1/1.2, ck / ckmb / troponin-t:241/12/0.39, albumin:2.8 g/dl, ldh:214 iu/l, ca++:8.6 mg/dl, mg++:2.0 mg/dl, po4:3.4 mg/dl assessment and plan 76 year old f with history a seizure disorder, chronic vent dependence transfered for hypoxia, and altered mental status. . # altered mental status: found to be in sub-clinical status epilepticus- unclear etiology. differential includes anoxic brain injury as patient had a pea prior to admission, toxic/metabolic encephalopathy from infection vs drugs (patient had mildly elevated dilantin level), or underlying seizure disorder.. mri negative for mass or infectious focus. she had a prior admission with similar altered mental status, however, eeg was negative at that time. she had an extensive neuro work up at that time which was largely unrevealing including lp, paraneoplastic labs which were negative, spep/upep, mri/mra brain, emg concerning for critical illness myopathy. persistent status epilepticus upon trying to wean of versed - lp cx ngtd - patient now on pentobarbitol gtt given persistent ncse - continue keppra and dilantin, levels at target goal - final read of mri shows l posterior parietal small infarct which is likely not contributing to overall picture per neuro - follow up eeg read - neuro recs - sural nerve biopsy for neuropathy once stable - family not willing to consent as patient in status . # respiratory failure - rsbi 199 - continue curretn vent settings - daily rsbi with sbt if appropriate . #volume status: - patient gradually more overloaded over last week, cxr with pleural effusions, will diurese with lasix with goal -500 today - hold bp meds . # constipation: had kub on admission showing stool in the [**last name (lf) 800**], [**first name3 (lf) **] have led to worsening residuals, vomiting and aspiration. s/p aggressive bowel regimen with bm at this time. regurgitation also improved at this time. will start senna and colace to assist with bm and avoid precipitating further aspiration. - aggressive bowel regimen, optimize regimen . # anemia: baseline appears to be 27-28. stable . # hypertension: per history hypertension mostly a problem during breathing trials. was initially normotensive in the setting of dehydration and potential infection so bp meds held. restarted on some home meds with some improvement in blood pressure. - labetalol 800 tid, clonidine, hydralazine, lopressor all being held given hypotension with dilantin/propofol. would restart labetalol first w/ hydralazine next for afterload reduction. icu care nutrition: glycemic control: lines: picc line - [**2115-4-21**] 05:45 pm prophylaxis: dvt: boots, sq uf heparin stress ulcer: vap: hob elevation, mouth care, daily wake up, rsbi comments: communication: comments: family meeting today to discuss long term goals of care code status: full code disposition: icu",1
173,"anemia, acute, secondary to blood loss (hemorrhage, bleeding) assessment: drainage from right lateral hip and thigh incision being monitored. continuous hemodynamic monitoring in progress. right ij triple lumen central line insitu with cvp monitoring. assess right thigh for extreme distention, thigh circumference measured for comparison, and distal pulses being assessed. trending lab valve monitoring with necessary interventions. action: right ij central line placed this am to facilitate monitoring of hemodynamic values. central line care per protocol being maintained.vss being done q1hr. peripheral pulse assessment done q4hr as needed. consented blood transfusions given in relevance to lab values. pad beneath right leg assessed frequently and changed as needed. continue iv therapy as ordered. response: no adverse reaction noted to blood transfusion, vss remain within acceptable limits for patient. dressing to right thigh soiled but intact. two pads moderately saturated with bloody drainage changed over the last 12hours. peripheral pulses remain weak but palpable with regular rate and rhythm. urinary output has picked up and is within acceptable limits. plan: continue cvp monitoring and other hemodynamic assessments. ivf as ordered. monitor urinary output and follow lab trends with appropriate interventions as needed. electrolyte & fluid disorder, other assessment: monitor skin integrity, vss and cvp values. trend lab values comparatively. monitor mg, na, k, and ca levels. observe for abnormal ekg rhythms. action: given magnesium sulfate for mg of 1.4 also received calcium gluconate for ca of 7.7. response: some general non pitting edema noted. urinary output remains adequate. lab value have not deteriorated. plan: continue se [**last name **] problem - [**name (ni) **] description in comments assessment: action: response: plan: diabetes mellitus (dm), type ii assessment: action: response: plan:",0
174,demographics day of intubation: [**2137-8-1**] day of mechanical ventilation: 2 ideal body weight: 69.9 none ideal tidal volume: 279.6 / 419.4 / 559.2 ml/kg airway tube type ett: position: 21 cm at teeth route: oral type: standard size: 7.5mm cuff pressure: 22 cmh2o lung sounds rll lung sounds: crackles rul lung sounds: clear lul lung sounds: clear lll lung sounds: crackles secretions sputum source/amount: suctioned / none plan next 24-48 hours: continue with daily rsbi tests & sbt's as tolerated; comments: rsbi=17 then weaned to psv 5/5/50%. plan is to extubate in am. initiated mdi s alb/atr q4 hrs prn and administered as ordered with no adverse reactions. am abg 7.38/38/161/22,0
175,lung sounds rll lung sounds: crackles rul lung sounds: clear lul lung sounds: diminished lll lung sounds: crackles comments: plan pt presently on 3 lpm n/c and ordered for nebs alb/atr. nebs administered as ordered with no adverse reactions.,0
176,lung sounds rll lung sounds: exp wheeze rul lung sounds: exp wheeze lul lung sounds: exp wheeze lll lung sounds: crackles comments: pt currently on 6l nc. nebs given as ordered with no adverse reaction.,0
177,demographics day of intubation: [**2154-7-27**] day of mechanical ventilation: 2 ideal body weight: 52.2 none ideal tidal volume: 208.8 / 313.2 / 417.6 ml/kg airway airway placement data known difficult intubation: yes procedure location: outside hospital tube type ett: position: 21 cm at teeth route: oral type: standard size: 7.5mm cuff pressure: 21 cmh2o cuff volume: ml / lung sounds rll lung sounds: rhonchi rul lung sounds: rhonchi lul lung sounds: rhonchi lll lung sounds: rhonchi comments: secretions sputum color / consistency: blood tinged / thick sputum source/amount: suctioned / small comments: most likely due to intubation ventilation assessment visual assessment of breathing pattern: pt has been brady since arrival from osh and has periods of apnea. plan next 24-48 hours: continue with daily rsbi tests & sbt's as tolerated. rsbi=9 (large tv s with low rr) reason for continuing current ventilatory support: intolerant of weaning attempts. no a-line. abg 7.55/39/197 on a/c.(see flow sheet)02 sats @ 100% pt arrived on a/c then weaned to mmv (psv 5/5/40%) pt is known **difficult intubation** mdi s ordered and administered combivent q4 hrs with no adverse reactions.,0
178,"demographics day of intubation: [**2154-7-27**] day of mechanical ventilation: 2 ideal body weight: 52.2 none ideal tidal volume: 208.8 / 313.2 / 417.6 ml/kg airway airway placement data known difficult intubation: yes procedure location: outside hospital tube type ett: position: 21 cm at teeth route: oral type: standard size: 7.5mm cuff pressure: 21 cmh2o cuff volume: ml / lung sounds rll lung sounds: rhonchi rul lung sounds: rhonchi lul lung sounds: rhonchi lll lung sounds: rhonchi comments: secretions sputum color / consistency: blood tinged / thick sputum source/amount: suctioned / small comments: most likely due to intubation ventilation assessment visual assessment of breathing pattern: pt has been brady since arrival from osh and has periods of apnea. plan next 24-48 hours: continue with daily rsbi tests & sbt's as tolerated. rsbi=9 (large tv s with low rr) reason for continuing current ventilatory support: intolerant of weaning attempts. no a-line. abg 7.55/39/197 on a/c.(see flow sheet)02 sats @ 100% pt arrived on a/c then weaned to mmv (psv 5/5/40%) pt is known **difficult intubation** mdi s ordered and administered combivent q4 hrs with no adverse reactions. ------ protected section ------ addendum to sputum color: pt was intubated on [**7-21**] at outside hospital. ------ protected section addendum entered by:[**name (ni) 1422**] [**last name (namepattern1) 4914**], rrt on:[**2154-7-28**] 04:46 ------",0
179,title: respiratory care: pt rec d on psv 5/5/40%. bs are coarse bilaterally with diminished bases. suctioned for small amounts of thick tan/yellow secretions. mdi s administered as ordered alb/atr with no 0s. pulmicort neb also administered in line with vent and tolerated well. no abg s this shift with rsbi=71. pt is a known difficult intubation and is expected to extubate in am. bronch cart/difficult airway cart to be at bedside.,0
180,title: respiratory care: pt rec d on psv 5/5/50%. bs are coarse bilaterally which clear with suctioning. suctioned for small to moderate amounts of thick white/yellow secretions. mdi s administered as ordered of alb with no adverse reactions. no abg s this shift 02 sats @ 99%. rsbi=34. plan: wean to sbt as tolerates with possible extubation this am.,0
181,demographics : day of mechanical ventilation: 6 ideal body weight: 45.4 none ideal tidal volume: 181.6 / 272.4 / 363.2 ml/kg airway airway placement data known difficult intubation: yes emergent intubation ett: position: 23 cm at teeth route: oral type: standard size: 7mm cuff pressure: 21 cmh2o cuff volume: 5 ml / airway problems: [**name2 (ni) 59**] leak with cuff down lung sounds rll lung sounds: diminished rul lung sounds: rhonchi lul lung sounds: rhonchi lll lung sounds: diminished mdi s administered combivent with no adverse reactions. secretions sputum color / consistency: yellow / thick sputum source/amount: suctioned / small comments: plan next 24-48 hours: continue with daily rsbi tests & sbt's as tolerates with possible wean to extubate today. rsbi=32 questionable whether pt is to return to [**hospital ward name **] and or to extubate due to difficult intubation and no cuff leak.,0
182,"title: respiratory: rec d pt on a/c 14/600/+8/40%. pt has # 8 air filled [**last name (un) **] trach. cuff pressure @ 21 cmh20. bs are coarse with diminished bases. suctioned for moderate amounts of thick bloody tinged and this am large brown plug. pt coughed up plug after lavarge. mdi administered of alb/atr with no adverse reactions. please note*** pt has extra length [**last name (un) **] trach, secured @9 at the flange, use caution when suctioning *** pt was originally scheduled for mri, but due to trach (metal rings) pt went to ct scan. results noted of cerebral edema and developing sinusitis. abg 7.43/36/140 with rsbi=220. pt continues to breath erratically, with noted ^ wob due to neuro status anoxic brain injury. family meeting today to discuss dnr/dni/cmo status.",0
183,"hypotension (not shock) assessment: neo gtt continues due to hypotension sbp in 80s while weaning gtt to off. see flowsheet for details. pt requiring neo gtt as high as 0.7mcg/kg/min. hct 29 this am. action: 1 unit of prbcs given as ordered. also 2 doses of albumin 25 gm given as ordered. echo done at bedside. response: no adverse reactions to prbcs, vss. at present able to wean neo to 0.4mcg/kg/min. see flowsheet for details. repeat hct 32. plan: wean neo gtt for sbp >90/ map >60. renal failure, end stage (end stage renal disease, esrd) assessment: today is normally a dialysis day for pt (m,w,f). creatinine 2.5. pt continues on neo gtt. action: renal team following pt. recommends no dialysis today d/t neo requirements and fluid requirements (albumin and prbcs). response: possible hd tomorrow if off of neo. plan: wean neo gtt as pt tolerates. if continues on neo gtt tomorrow ? to start cvvdhf. atrial fibrillation (afib) assessment: pt continues in afib. received pt with hr 80-90s w/ occasional pvcs and rare runs of vt/ action: k+ repleted as ordered. amio bolus and gtt started as ordered. digoxin changed to everyday d/t pt needing the inotropic effect. response: repeat k 3.5, repleted with additional 20meq iv kcl. amio gtt decreased at 1400 to 0.5mg/min as per pa due to hr 58-60s. plan: monitor rhythm. watch k+. amio gtt to continue at 0.5mg/min. gastrointestinal bleed, other (gi bleed, gib) assessment: pt passing loose black stool. +guiac. action: [**doctor last name 5638**] aware. lactulose and senakot discontinued. response: repeat hct 32. continues to have loose black stool. not as frequent. plan: monitor hct. gi team following pt and aware of the stool. dementia (including alzheimer's, multi infarct) assessment: as day progressed pt noted to be more lethargic, though easily arousable. oriented. action: [**doctor last name 5638**] aware. abg and lytes sent as per pa. response: labs reviewed by pa. acceptable abg. creatinine pending. plan: monitor neuro status.",0
184,"chief complaint: 24 hour events: blood cultured - at [**2131-9-26**] 11:00 am from ij stool culture - at [**2131-9-26**] 02:00 pm guiac neg pain control overnight w/ oxycontin/oxycodone nurse called to report occaisonal runs of [**5-1**] pvcs/vtac, not sustained, periodic. pt sleeping comfortably. allergies: levofloxacin hives; cefazolin nausea/vomiting coreg (oral) (carvedilol) fatigue; dopamine ventricular tac last dose of antibiotics: piperacillin/tazobactam (zosyn) - [**2131-9-27**] 12:00 am vancomycin - [**2131-9-27**] 12:00 am infusions: other icu medications: ranitidine (prophylaxis) - [**2131-9-26**] 09:00 am enoxaparin (lovenox) - [**2131-9-26**] 11:30 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2131-9-27**] 06:37 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.4 c (97.5 tcurrent: 36.4 c (97.5 hr: 73 (60 - 90) bpm bp: 97/41(56) {92/41(54) - 116/64(76)} mmhg rr: 14 (0 - 20) insp/min spo2: 95% heart rhythm: v paced height: 69 inch cvp: 0 (0 - 25)mmhg total in: 1,784 ml 316 ml po: 600 ml 150 ml tf: ivf: 1,184 ml 166 ml blood products: total out: 2,049 ml 510 ml urine: 1,349 ml 510 ml ng: stool: 700 ml drains: balance: -265 ml -194 ml respiratory support o2 delivery device: nasal cannula spo2: 95% abg: ///20/ physical examination eyes / conjunctiva: perrl, pupils dilated cardiovascular: (s1: normal), (s2: distant) peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) abdominal: soft, non-tender, bowel sounds present extremities: right: absent, left: absent musculoskeletal: muscle wasting skin: not assessed, r bka red, mild tender, not-fluctuant neurologic: attentive, responds to: not assessed, movement: not assessed, tone: not assessed labs / radiology 328 k/ul 12.4 g/dl 95 mg/dl 1.7 mg/dl 20 meq/l 5.0 meq/l 72 mg/dl 107 meq/l 136 meq/l 39.4 % 20.9 k/ul [image002.jpg] [**2131-9-25**] 11:30 pm [**2131-9-26**] 05:02 am [**2131-9-26**] 05:31 pm wbc 31.7 28.4 20.9 hct 43.6 41.1 39.4 plt [**telephone/fax (3) 5746**] cr 1.6 1.7 1.7 tropt 0.08 glucose 126 71 95 other labs: pt / ptt / inr:19.3/40.6/1.8, ck / ckmb / troponin-t:50/6/0.08, alt / ast:18/20, alk phos / t bili:118/0.3, amylase / lipase:108/44, differential-neuts:92.0 %, band:2.0 %, lymph:3.0 %, mono:2.0 %, eos:0.0 %, lactic acid:1.4 mmol/l, albumin:3.4 g/dl, ldh:361 iu/l, ca++:8.4 mg/dl, mg++:1.8 mg/dl, po4:5.9 mg/dl assessment and plan 66 y/o m with pmh of dm type 2, ischemic cardiomyopathy, and pvd s/p r bka admitted with diarrhea, hypotension and elevated wbc consistent with sepsis. . # hemodynamics: improved on 1.1 phenylphrine overnight. known ef 20%. maps in the 70s. sbp 90 - 110s. - will get cvp transduced via l ij - asses scv02 to determine cardiogenic vs septic etiology of patient hypotension. - will provide ivf pending above results and follow with clinical exams. # infectious source: skin/soft tissue vs c. diff. patients wbc is elevated in setting of run of vt overnight so difficult to base response to antibiotics this am with wbc going from 20 -> 30k. - follow-up blood cultures, urine cultures, stool for c. diff - will fluid resuscitate, but gently given poor ef. - continue broad spectrum abx with zosyn/vancomycin while cultures pending - touch base with patients vascular surgeon for evaluation. - cont vanco po for possible c. diff given loose stools, f/u culture . # ventricular tachycardia: per ep this morning patients episode of last night was vt from likely same site as prior episodes. - continue lidocaine drip for 24hrs - restart amiodarone 200 po daily - tomorrow will begin mexilitine 150mg [**hospital1 **] - to be assessed by ep team tomorrow for potential icd implantation. - ep to evaluate in morning - may need icd implantation . # ischemic cardiomyopathy: holding bp medications in setting of hypotension. - cautious ivf - pressor support as needed (with phenylephrine, avoiding dobutamine given past adverse reactions). - telemetry . # chronic renal failure: cr. 1.7 today at baseline. - continue to monitor, renally dose medications . # diabetes: continue home dose nph, iss. . # hypercoagulability: - curently holding lovenox however will likely restart this pm following discussion with other servicees at to whether pt will need to go to other procedures in the immediate future . # depression: - cont citalopram. . # neuropathy: oxycontin, neurontin, vicodin. . # ppx: holding lovenox as above, will restart, pneumoboots. . # full code . # contact: [**name (ni) 3848**] [**name (ni) 5723**] [**telephone/fax (1) 5724**] (c), [**telephone/fax (1) 5725**] (h icu care nutrition: glycemic control: lines: 18 gauge - [**2131-9-25**] 09:15 pm 20 gauge - [**2131-9-25**] 09:15 pm multi lumen - [**2131-9-26**] 12:00 am prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: full code disposition:",1
185,"chief complaint: 24 hour events: blood cultured - at [**2131-9-26**] 05:00 am rij tlc brown port blood cultured - at [**2131-9-26**] 05:30 am venipuncture central line placed. repositioned and pulled back 3 cm following radiology confirmation. allergies: levofloxacin hives; cefazolin nausea/vomiting coreg (oral) (carvedilol) fatigue; dopamine ventricular tac last dose of antibiotics: piperacillin/tazobactam (zosyn) - [**2131-9-25**] 11:30 pm vancomycin - [**2131-9-26**] 08:00 am infusions: phenylephrine - 1.1 mcg/kg/min lidocaine - 1 mg/min other icu medications: insulin - humalog - [**2131-9-26**] 12:00 am ranitidine (prophylaxis) - [**2131-9-26**] 09:00 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: constitutional: no(t) fatigue, no(t) fever ear, nose, throat: no(t) dry mouth cardiovascular: no(t) chest pain, no(t) palpitations, no(t) edema respiratory: no(t) cough, no(t) dyspnea gastrointestinal: no(t) abdominal pain, no(t) nausea, no(t) emesis, diarrhea genitourinary: wants foley out musculoskeletal: no(t) joint pain neurologic: no(t) headache flowsheet data as of [**2131-9-26**] 12:19 pm vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.4 c (99.4 tcurrent: 36.2 c (97.2 hr: 70 (60 - 144) bpm bp: 105/63(72) {64/46(53) - 110/90(93)} mmhg rr: 10 (0 - 20) insp/min spo2: 97% heart rhythm: v paced height: 69 inch total in: 1,825 ml 819 ml po: 240 ml tf: ivf: 1,125 ml 579 ml blood products: total out: 350 ml 389 ml urine: 350 ml 389 ml ng: stool: drains: balance: 1,475 ml 430 ml respiratory support o2 delivery device: nasal cannula spo2: 97% abg: ///19/ physical examination eyes / conjunctiva: perrl, pupils dilated cardiovascular: (s1: normal), (s2: distant) peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) abdominal: soft, non-tender, bowel sounds present extremities: right: absent, left: absent musculoskeletal: muscle wasting skin: not assessed, r bka red, mild tender, not-fluctuant neurologic: attentive, responds to: not assessed, movement: not assessed, tone: not assessed labs / radiology 433 k/ul 13.3 g/dl 71 mg/dl 1.7 mg/dl 19 meq/l 5.1 meq/l 72 mg/dl 107 meq/l 137 meq/l 41.1 % 28.4 k/ul [image002.jpg] [**2131-9-25**] 11:30 pm [**2131-9-26**] 05:02 am wbc 31.7 28.4 hct 43.6 41.1 plt 416 433 cr 1.6 1.7 tropt 0.08 glucose 126 71 other labs: pt / ptt / inr:19.3/40.6/1.8, ck / ckmb / troponin-t:50/6/0.08, differential-neuts:92.0 %, band:2.0 %, lymph:3.0 %, mono:2.0 %, eos:0.0 %, ca++:8.4 mg/dl, mg++:1.8 mg/dl, po4:5.9 mg/dl assessment and plan 66 y/o m with pmh of dm type 2, ischemic cardiomyopathy, and pvd s/p r bka admitted with diarrhea, hypotension and elevated wbc consistent with sepsis. . # hemodynamics: improved on 1.1 phenylphrine overnight. known ef 20%. maps in the 70s. sbp 90 - 110s. - will get cvp transduced via l ij - asses scv02 to determine cardiogenic vs septic etiology of patient hypotension. - will provide ivf pending above results and follow with clinical exams. # infectious source: skin/soft tissue vs c. diff. patients wbc is elevated in setting of run of vt overnight so difficult to base response to antibiotics this am with wbc going from 20 -> 30k. - follow-up blood cultures, urine cultures, stool for c. diff - will fluid resuscitate, but gently given poor ef. - continue broad spectrum abx with zosyn/vancomycin while cultures pending - touch base with patients vascular surgeon for evaluation. - cont vanco po for possible c. diff given loose stools, f/u culture . # ventricular tachycardia: per ep this morning patients episode of last night was vt from likely same site as prior episodes. - continue lidocaine drip for 24hrs - restart amiodarone 200 po daily - tomorrow will begin mexilitine 150mg [**hospital1 **] - to be assessed by ep team tomorrow for potential icd implantation. - ep to evaluate in morning - may need icd implantation . # ischemic cardiomyopathy: holding bp medications in setting of hypotension. - cautious ivf - pressor support as needed (with phenylephrine, avoiding dobutamine given past adverse reactions). - telemetry . # chronic renal failure: cr. 1.7 today at baseline. - continue to monitor, renally dose medications . # diabetes: continue home dose nph, iss. . # hypercoagulability: - curently holding lovenox however will likely restart this pm following discussion with other servicees at to whether pt will need to go to other procedures in the immediate future . # depression: - cont citalopram. . # neuropathy: oxycontin, neurontin, vicodin. . # ppx: holding lovenox as above, will restart, pneumoboots. . # full code . # contact: [**name (ni) 3848**] [**name (ni) 5723**] [**telephone/fax (1) 5724**] (c), [**telephone/fax (1) 5725**] (h icu care nutrition: glycemic control: lines: 18 gauge - [**2131-9-25**] 09:15 pm 20 gauge - [**2131-9-25**] 09:15 pm dispoition: micu (in ccu) pending clinical improvement.",1
186,"hpi: this is a 45 yo m with etoh cirrhosis and grade ii esophageal varices s/p banding in [**7-19**]. notes that yesterday and today he had dark stools. then he noted at 3pm today he ate some lunch and felt nauseous and subsequently had ~ 1 cup of hematemesis- bright red. denies having had any since. pt states that he has a 6 pack of mikes hard lemonade daily, plus occasional tumbler of cognac. his last drink was on [**2173-1-1**]. .h/o esophageal varices assessment: pt has had no vomiting since his admit to the icu. action: pt had an egd done upon arrival to the floor. pt received a total of 125mcg of fentanyl and 3mg of versed. pt had 3 banding done during procedure. response: hct post procedure was 34.5. pt has c/o sore throat, however no other complaints of pain or discomfort. pt has an octreotide gtt running at 50mcg/hr. gag reflex intact, pt given a small cup of ice chips with no adverse reactions. am lab hct 32.9 plan: monitor hct. continue octreotide gtt. provide emotional support. .h/o cirrhosis of liver, alcoholic assessment: pt has had no stool since admission. liver enzymes with am labs sent. pt states that he has a 6 pack of mikes hard lemonade daily, plus occasional tumbler of cognac action: md reminded pt the importance of him to stop drinking. response: pt stated, i know i have to stop but at least i am not drinking as much as i used to. ast = 62 plan: continue providing emotional support to the pt in regards to drinking. continue reinforcing the importance of him not drinkning.",0
187,"title: respiratory care: pt rec d on 4 lpm n/c, 02 sats @ 95%. bs are diminished bilaterally. nebs administered q6 hrs alb/atr (unit dose) with no adverse reactions, no improvement noted following tx.",0
188,"patient states she has had a 'cold' for approximately one week, with a productive cough, she denies any fever. brownish expectorant at times. developed extreme dyspnea at home today and called 911where she was brought to the ed. on admission to the ed patient was in respiratory distress, placed on cpap, given lasix 100mg iv. the ed team had a difficult time obtaining iv access (per their report) but did eventually place a left femoral central line emergently.hypertensive with initial bp 258/123 hr 110bpm treated with sl captopril 6.25 and placed on ntg transiently with effect. for dialysis on arrival to unit. heart failure (chf), diastolic, chronic with respiratory difficulty. assessment: cxr suggestive of chf/pna, bnp pending. patient also has an h/o of chf. action: on arrival to the unit patient to receive dialysis, she is also s/p lasix iv 100mg with no little to no result. on cpap for optimal ventilation and she is quite cooperative. response: patient tolerated cpap for a couple hours. after 1.5hrs dialysis respirations improved and switched to 50% ventimask and maintaining saturations in the upper 90 plan: continue to monitor respiratory status and follow lab trends. renal failure, chronic (chronic renal failure, crf, chronic kidney disease) assessment: esrd on mwf, possible fluid overload on this admission. left av fistula positive for thrill and bruit. action: continue with dialysis [**name8 (md) **] md recommendations. response: pt. tolerating dialysis well without any adverse reaction. plan: continue to monitor fluid and electrolyte balance.",0
189,"hpi: this is a 45 yo m with etoh cirrhosis and grade ii esophageal varices s/p banding in [**7-19**]. notes that yesterday and today he had dark stools. then he noted at 3pm today he ate some lunch and felt nauseous and subsequently had ~ 1 cup of hematemesis- bright red. denies having had any since. pt states that he has a 6 pack of mikes hard lemonade daily, plus occasional tumbler of cognac. his last drink was on [**2173-1-1**]. .h/o esophageal varices assessment: pt has had no vomiting since his admit to the icu. action: pt had an egd done upon arrival to the floor. pt received a total of 125mcg of fentanyl and 3mg of versed. pt had 3 banding done during procedure. response: hct post procedure was 34.5. pt has c/o sore throat, however no other complaints of pain or discomfort. pt has an octreotide gtt running at 50mcg/hr. gag reflex intact, pt given a small cup of ice chips with no adverse reactions. plan: monitor hct. continue octreotide gtt. provide emotional support. .h/o cirrhosis of liver, alcoholic assessment: pt has had no stool since admission. liver enzymes with am labs sent. pt states that he has a 6 pack of mikes hard lemonade daily, plus occasional tumbler of cognac action: md reminded pt the importance of him to stop drinking. response: pt stated, i know i have to stop but at least i am not drinking as much as i used to. plan: continue providing emotional support to the pt in regards to drinking. continue reinforcing the importance of him not drinkning.",0
190,"hpi: this is a 45 yo m with etoh cirrhosis and grade ii esophageal varices s/p banding in [**7-19**]. notes that yesterday and today he had dark stools. then he noted at 3pm today he ate some lunch and felt nauseous and subsequently had ~ 1 cup of hematemesis- bright red. denies having had any since. pt states that he has a 6 pack of mikes hard lemonade daily, plus occasional tumbler of cognac. his last drink was on [**2173-1-1**]. .h/o esophageal varices assessment: pt has had no vomiting since his admit to the icu. action: pt had an egd done upon arrival to the floor. pt received a total of 125mcg of fentanyl and 3mg of versed. pt had 3 banding done during procedure. response: hct post procedure was 34.5. pt has c/o sore throat, however no other complaints of pain or discomfort. pt has an octreotide gtt running at 50mcg/hr. gag reflex intact, pt given a small cup of ice chips with no adverse reactions. am lab hct 32.9 plan: monitor hct. continue octreotide gtt. provide emotional support. .h/o cirrhosis of liver, alcoholic assessment: pt has had no stool since admission. liver enzymes with am labs sent. pt states that he has a 6 pack of mikes hard lemonade daily, plus occasional tumbler of cognac. action: md reminded pt the importance of him to stop drinking. response: pt stated, i know i have to stop but at least i am not drinking as much as i used to. ast = 62 plan: continue providing emotional support to the pt in regards to drinking. continue reinforcing the importance of him not drinkning.",0
191,"patient states she has had a 'cold' for approximately one week, with a productive cough. brownish expectorant at times. developed extreme dyspnea at home today and called 911where she was brought to the ed. on admission patient was in respiratory distress, placed on cpap, given lasix 100mg iv. hypertensive with initial bp 258/123 treated with sl captopril 6.25 and placed on ntg transiently with effect. left femoral tl cl placed. for dialysis on arrival to unit. heart failure (chf), diastolic, chronic with respiratory difficulty. assessment: cxr suggestive of chf/pna, bnp pending. patient also has an h/o of chf. action: on arrival to the unit patient to receive dialysis, she is also s/p lasix iv 100mg with no little to no result. on cpap for optimal ventilation and she is quite cooperative. response: patient tolerated cpap for a couple hours. after 1.5hrs dialysis respirations improved and switched to 50% ventimask and maintaining saturations in the upper 90 plan: continue to monitor respiratory status and follow lab trends. renal failure, chronic (chronic renal failure, crf, chronic kidney disease) assessment: esrd on mwf, possible fluid overload on this admission. left av fistula positive for thrill and bruit. action: continue with dialysis [**name8 (md) **] md recommendations. response: pt. tolerating dialysis well without any adverse reaction. plan: continue to monitor fluid and electrolyte balance.",0
192,demographics ideal body weight: 75.3 none ideal tidal volume: 301.2 / 451.8 / 602.4 ml/kg airway tracheostomy tube: type: perc trach manufacturer: portex size: 8.0mm pmv: cuff management: vol/press: cuff pressure: 25 cmh2o cuff volume: 9 ml / airway problems: comments: lung sounds rll lung sounds: diminished rul lung sounds: clear lul lung sounds: clear lll lung sounds: diminished comments: secretions sputum color / consistency: white / thin sputum source/amount: suctioned / moderate comments: ventilation assessment level of breathing assistance: unassisted spontaneous breathing visual assessment of breathing pattern: assessment of breathing comfort: no claim of dyspnea) plan next 24-48 hours: pt remains on 50% t/c noc and tolerated well. mdi's atr/ald administered via trach with no adverse reactions. 02 sats @ 95-96%. continue to monitor pt x24 hrs for any distress requiring additonal support by vent.,0
193,"mr. [**known lastname 7698**] is a 52 y.o. m with history of recurrent mssa epidural abscesses s/p debridement x2 and history of endocarditis s/p mvp, who presents with fever, chills, neck stiffness and right-sided paraesthesias x3 days. pmh is notable for a complicated course of mssa bacteremia in [**2147**] (described in detail below). in brief, pt was treated (surgically and medically) in [**4-2**] for mssa epidural abscesses of the cervical, thoracic, and lumbar spine, osteomyelitis of the r elbow, and osteomyelitis of the r foot (positive for pseudomonas). hospital course was complicated by worsening mv regurgitation necessitating repair, arf necessating hemodyalysis (through [**5-2**]), and afib (since resolved). recurrent mssa bacteremia/paraspinal involvement in [**8-2**] requiring debridement and abiotic rx w/ cefazolin. he was transferred here to micu on [**2149-1-22**] with worsening sob, fevers. blood cultures are positive and pt may have recurrent endocarditis vs vegitation. tte done [**2149-1-22**] was not helpful and pt was scheduled for tee today. npo overnight. required intubation for the tee due to hypoxia. pt given 40mg iv lasix at 10:30 as ordered and foley inserted for diuresis effect. .h/o endocarditis, bacterial assessment: pt ruled in with positive blood cultures for mssa bacteremia. underwent tee on[**1-23**] found large vegetation on mitral valve action: nafcillin desensitization ordered, and started @ 1210 response: pt cont on iv gentamycin. cefazolin continues at 2gm iv q24hr. no adverse reaction to nafcillin desensetization plan: continue to observe in micu and continue antibiotics. if pt tolerates nafcillin w/o reaction the plan is to d/c cefazolin and cont with iv nafcillin per id acute pain assessment: pt has continued complaints of neck pain [**5-4**] action: cont with morphine iv 4mg w/ valium 2mg as ordered response: pt pain level more controlled today with the use of valium plan: continue to assess and treat pain as needed. pneumonia, bacterial, community acquired (cap) assessment: pt s cxr looking showing ? fluid overload. action: pt given lasix 40mg x 1 dose response: diuresing well from the lasix. plan: cont iv lasix until patient is negative 1l.",0
194,"patient is a 86y/o m with a pmh of biventricular chf with ef 15%, s/p cabg [**2167**]. presenting on [**1-16**] from osh with complete heart block. s/p permanent pacemaker [**1-16**], now extubated & off all pressor support. ppm set at ddd, rate of 60. has short term memory deficit @ baseline, now exacerbated by sedation drugs/ renal failure. altered mental status (not delirium) assessment: conts to be restless at times, crying out for help. a+ox2, severe short tem memory deficit, constant reminding pt he has a foley. urine remains pink/ red, some clots. action: one time haldol dose given. irrigated foley once. lasix 20mg x1. sons @ bedside to help orientate. speech & swallow consulted. response: fair results from haldol, no attempts to pull line/ tubes. good urine flow from foley, fair results from lasix. passed speech/ swallow-> on nectar thick liquid diet. plan: maintain safety precautions. impaired skin integrity assessment: c/o skin itch on back, red rash noted on l flank/ back. action: lotion applied, ordered for ursodiol. ? benadryl adverse reaction. response: ursodiol d/c d, ordered for sarna lotion. plan: monitor l flank area rash for broken skin. ? drug reaction.",1
195,"86y/o m with a pmh of biventricular chf with ef 15%, presenting on [**1-16**] from osh with chb. s/p permanent pacemaker [**1-16**], now extubated & off all pressor support. ppm set at ddd, rate of 60. has short term memory deficit @ baseline, now exacerbated by sedation drugs/ renal failure. currently day [**1-24**] clindamycin. no clear evidence of pna on cxr, likely pulmonary edema related to severe chf, ? pna given increased sputum production. speech and swallow consult [**1-18**] hematuria assessment: continues to c/o urge to void, attempting to get oob to urinate. urine appearing more red, urine continues to come out of urethral orifice action: foley irrigated. flomax started last night. response: flushed easily, urine noted to come out of urethra. sm clots noted when aspirated back. foley continues to drain adequate amts red urine 30-60cc/hr plan: keep foley in place, irrigate prn, ? urology consult. altered mental status (not delirium) underlying dementia assessment: ms waxes and wanes. calling out for help. restless at times appearing to be r/t urinary discomfort and need to move bowels. oriented [**11-26**]. short term memory loss. asking appropriate questions re: events that led to hospitalization. attempted to get oob mult times during the night. did not sleep most of night, very short naps ~10min action: 1mg haldol iv x1 given at 2330. pt frequently re-oriented, 1:1 supervision until pt calm response: no effect with haldol. no change in ms [**name13 (stitle) 440**]: continue safety precautions, re-orient prn, avoid benzodiazepines & anti-cholinergic meds. hypotension (not shock) assessment: bps via l radial aline 130-140s/50-70s action: half-dose of pt s home dose coreg re-started last night. aline dcd at 0400. response: tolerated coreg plan: continue present management. check csm l hand heart failure (chf), severe biventricular systolic heart failure, acute on chronic assessment: mild non-pitting [**11-25**]+ ble edema. o2 sat 98-100% on 2l nc action: o2 weaned off response: sats wnl, >95% plan: chf management, strict i/os. gentle diuresis with lasix given pre-load dependent. goal neg 500cc/day pleural effusion assessment: action: response: plan: impaired skin integrity assessment: c/o skin itch on back, red rash noted on l flank/ back. action: lotion applied, ordered for ursodiol. ? benadryl adverse reaction. response: ursodiol d/c d, ordered for sarna lotion. plan: monitor l flank area rash for broken skin. ? drug reaction. - sputum - f/u pa/lat cxr cr 3.2 on admission, history of ckd with cr ranging from 2.5-3. cr improved today to 2.7. patient is a",1
196,comments: lung sounds rll lung sounds: rhonchi rul lung sounds: rhonchi lul lung sounds: rhonchi lll lung sounds: rhonchi comments: ventilation assessment level of breathing assistance: unassisted spontaneous breathing visual assessment of breathing pattern: normal quiet breathing assessment of breathing comfort: no claim of dyspnea) plan next 24-48 hours: nebs administered atr and xopenex q6 hrs. with no adverse reactions. will continue to follow reason for continuing current ventilatory support:,0
197,"mr. [**known lastname 7698**] is a 52 y.o. m with history of recurrent mssa epidural abscesses s/p debridement x2 and history of endocarditis s/p mvp, who presents with fever, chills, neck stiffness and right-sided paraesthesias x3 days. pmh is notable for a complicated course of mssa bacteremia in [**2147**] (described in detail below). in brief, pt was treated (surgically and medically) in [**4-2**] for mssa epidural abscesses of the cervical, thoracic, and lumbar spine, osteomyelitis of the r elbow, and osteomyelitis of the r foot (positive for pseudomonas). hospital course was complicated by worsening mv regurgitation necessitating repair, arf necessating hemodyalysis (through [**5-2**]), and afib (since resolved). recurrent mssa bacteremia/paraspinal involvement in [**8-2**] requiring debridement and a biotic rx w/ cefazolin. he was transferred here to micu on [**2149-1-22**] with worsening sob, fevers. blood cultures are positive and pt may have recurrent endocarditis vs vegetations. tte done [**2149-1-22**] was not helpful and pt was scheduled for tee today. npo overnight. required intubation for the tee due to hypoxia. pt given 40mg iv lasix at 10:30 as ordered and foley inserted for diuresis effect. .h/o endocarditis, bacterial assessment: pt ruled in with positive blood cultures for mssa bacteremia. underwent tee on[**1-23**] found large vegetation on mitral valve action: nafcillin desensitization started @ 1210 and reg dose received at 2000hrs response: pt cont on iv gentamycin. cefazolin continues at 2gm iv q24hr. no adverse reaction to nafcillin desensetization plan: continue antibiotics. if pt tolerates nafcillin w/o reaction the plan is to d/c cefazolin and cont with iv nafcillin per id acute pain assessment: pt has chronic neck pain, currently no pain , received pain meds at 6pm action: cont with morphine iv 4mg w/ valium 2mg as ordered response: pt pain level more controlled during day with the use of valium plan: continue to assess and treat pain as needed. pneumonia, bacterial, community acquired (cap) assessment: pt s cxr looking showing? fluid overload. action: pt given lasix 40mg x 1 dose during day response: diuresing well from the lasix. plan: cont to monitor uo. demographics attending md: [**doctor last name **] [**doctor last name **] f. admit diagnosis: fever code status: full code height: 72 inch admission weight: 110 kg daily weight: allergies/reactions: nafcillin sodium rash; precautions: pmh: renal failure cv-pmh: arrhythmias, chf additional history: epidural abcess [**date range (1) 7724**]. dev'p mssa bacteremia, complicated by epidural abcesses of the c,t, and l spine as well as septic arthritis of left elbow and osteo of foot >>> required multiple or's with ortho. then admission complicated by flail mitral cusp and worsening regurg/chf >>> mvrepair done. pt. had arf post-op and was on cvvh until [**4-26**]. pt readmitted [**2063-5-13**] for af/sync. and was started on coumadin (since stopped.) admitted [**2067-8-16**] with mssa bacteremia/paraspinal and underwent multiple debridements/washouts of deep lumbar spins, [**3-30**], ans l5-s1. pt. on cefazolin; course completed [**2148-10-14**]. surgery / procedure and date: multiple ortho spine - see chart. latest vital signs and i/o non-invasive bp: s:126 d:65 temperature: 97.6 arterial bp: s: d: respiratory rate: 15 insp/min heart rate: 86 bpm heart rhythm: sr (sinus rhythm) o2 delivery device: nasal cannula o2 saturation: 98% % o2 flow: 5 l/min fio2 set: 40% % 24h total in: 900 ml 24h total out: 4,090 ml pertinent lab results: sodium: 132 meq/l [**2149-1-24**] 05:46 pm potassium: 3.8 meq/l [**2149-1-24**] 05:46 pm chloride: 89 meq/l [**2149-1-24**] 05:46 pm co2: 33 meq/l [**2149-1-24**] 05:46 pm bun: 18 mg/dl [**2149-1-24**] 05:46 pm creatinine: 1.0 mg/dl [**2149-1-24**] 05:46 pm glucose: 144 mg/dl [**2149-1-24**] 05:46 pm hematocrit: 26.5 % [**2149-1-24**] 05:26 am finger stick glucose: 159 [**2149-1-24**] 06:00 pm valuables / signature patient valuables: other valuables: clothes: sent home with: wallet / money: no money / wallet cash / credit cards sent home with: jewelry: transferred from: micu 6 transferred to: [**hospital ward name 790**] 214 date & time of transfer: [**2149-1-24**]",0
198,"chief complaint: unresponsive hpi: 53 year old man with h/o aml s/p allo cord transplant (now day +516) complicated by chronic gvhd with arthritis, boop, who presented to the bmt floor from clinic with worsening renal function(2.3), hyperkalemia, and worsening odynophagia. on arrival to the bmt floor, as he was transitioning into the bed, he became mom[**name (ni) **] unresponsive to verbal stimuli and physical stimuli. no jerking movements or incontience were noted. a code blue was called. on arrival of the code team, bp 124/80, hr 70s, satting 100% on 5l nc. he was responsive to verbal stimuli and answering questions appropriately. 1 amp of d50, 10units regular insulin, and abuterol nebs were given for known hyperkalemia. an ekg was obtained which showed isolated peaked t waves. an abg was sent off with normal lactate and k returning at 6.5. cxr showed no interval change when accounted for technique from prior in the day. one set of blood cultures and cardiac enzymes were obtained, and 1amp calcium gluconate was initiated for hyperkalemia. during this time, the patient reported intermittent pains in his forehead, jaw, and right thigh area. he had 2 more episodes where he closed his eyes and was not immediately arousable to verbal stimuli. he had one episode of shakes and given immunosuppression and concern for infection, he received 1gm cefepime. . on arrival to the [**hospital unit name 44**], he reported chest discomfort and left arm numbness. ekg remained at baseline without st/t wave changes. his chest pain responded prior to administration of sl nitroglycerin. . on review of systems, during the period on the bmt floor he denied visual changes, vertigo, abdominal pain, fevers, sweats. over the past week, he has noted constipation, left elbow pain, pain with solids/liquids swallowing, acid reflux, and myalgias. recently completed course of po keflex for ingrown toe nail. patient admitted from: [**hospital1 54**] [**hospital1 55**] history obtained from patient, family / [**hospital 56**] medical records allergies: benadryl allergy (oral) (diphenhydramine hcl) urinary retenti ambisome (intraven.) (amphotericin b liposome) back pain; flomax (oral) (tamsulosin hcl) cough; rhinorrh last dose of antibiotics: cefepime on floor prior to transfer infusions: other icu medications: other medications: home -acyclovir 400 [**hospital1 **] -carvedilol 12.5 [**hospital1 **] -cyanocobalamin 1000mcg im 1xmonth -nexium 20mg po bid -furosemide 40mg po bid -gabapentin 300 cap 3caps tid -insulin novolog 4xday, sliding scale -glargine 10u qhs -lisinopril 5mg daily -montelukast 10mg po daily -morphine 15mg po q6-8 hrs prn pain -mmf 500mg tid -nitro 0.3mg tab sl -zofran 4-8mg q8 hrs prn nausea -oxycodone sr 10mg po bid -prednisone 20mg daily -bactrim 800-160 mwf -voriconazole 200mg tab, 1.5 tab q12h -aa magnesium sulfate otc 1tab daily -vit c 500mg tab daily -aspirin 81 mg tab enteric coated -cal carb 1000mg tab [**hospital1 **] -vit d3 400u daily -hexavitamin 1 tab daily -thiamine 50mg po daily -docusate 100mg po bid -senna 1 tab [**hospital1 **] prn past medical history: family history: social history: past oncologic history: 1) aml, m5b diagnosed 07/[**2182**]. - received induction chemotherapy with 7 + 3(ara-c and idarubicin)-[**2182-7-23**] until [**2182-8-22**]. the patient achieved a cr after this therapy. - high-dose ara-c x 2 cycles from [**2182-8-28**] until [**2182-9-27**]. - pt found to have relapsing dz and reinduced with mitoxantrone and ara-c [**date range (1) 1416**]. pt was found to have relapsing dz on bone marrow bx [**2183-9-2**] with 16% blasts, then was admitted between [**date range (1) 1417**] for mitoxantrone, etopiside and cytarabine. - s/p myeloablative sequential unrelated double cord blood transplant, now d+516. day 100 bone marrow biopsy showed no iagnostic morphologic features of involvement by acute leukemia, with cytogenetics revealing karyotype 46xx, consistent with that of female donor. . past medical & surgical history: past medical history (taken from previous notes) 2) hepatic insufficiency due to secondary hemochromatosis and steatosis 3) aspergillosis of the sinus/nares on voriconazole. 4) bacillary angiomatosis 5) acute appendicitis deep into his nadir during transplant that was successfully treated with daptomycin, meropenem, levofloxain and metronidazole 6) incidental hhv6 igg-positive, without disease 7) hx of post chemo-induced cardiomyopathy; tte [**6-19**] with preserved ef. 8) sarcoid - diagnosed in [**2172**], received intermittent steroids 9) gerd 10) htn 11) hypercholesterolemia 12) s/p cholecystectomy in [**6-/2180**] complicated by sinus tract to the abdominal wall 13) hepatic and splenic microabscesses/candidiasis ([**8-/2182**]) 14) boop requiring extended icu/hospital course in [**3-/2184**] and home oxygen 15) peripheral neuropathy noncontributory. occupation: drugs: tobacco: past, no current alcohol: other: formerly worked as auto mechanic, now disabled econdary to aml and gvhd. lives with wife, teenage son. review of systems: flowsheet data as of [**2185-4-20**] 10:39 pm vital signs hemodynamic monitoring fluid balance 24 hours since 12 am hr: 84 (67 - 89) bpm bp: 131/76(88) {122/72(85) - 153/79(96)} mmhg rr: 10 (10 - 16) insp/min spo2: 100% heart rhythm: sr (sinus rhythm) total in: po: tf: ivf: blood products: total out: 0 ml 200 ml urine: 200 ml ng: stool: drains: balance: 0 ml -200 ml respiratory o2 delivery device: nasal cannula spo2: 100% abg: ///18/ physical examination general: middle-aged, cushingoid, overweight man in nad heent: eomi, perrla, mucous membranes moist, no cervical lad, no jvd, neck supple w/out tenderness cardiac: rrr no m/g/r, s1, s2 nl chest: kyphotic lung: few bilateral crackles at bases, no wheezes, rhonchi abdomen: obese, soft, nt, nd, unable to appreciate hsm [**2-14**] body habitus, no rebound or guarding ext: warm, + bilateral 2+ pitting edema to knees, dp+ bilaterally, no cyanosis - l elbow medial epicondyle tenderness w/ effusion, no joint erythema or effusion neuro: cnii-xii intact, motor symmetric strength, hyperesthetic sensation bilateral le/feet, no evidence of toe nail erythema derm: ecchymoses on abdomen [**2-14**] insulin, no other lesions. psych: mood liabile, affect appropriate, intermittently tearing up to labs draws, movement to icu labs / radiology 95 k/ul 7.8 g/dl 108 mg/dl 2.1 mg/dl 74 mg/dl 18 meq/l 126 meq/l 4.8 meq/l 136 meq/l 23.5 % 3.5 k/ul [image002.jpg] [**2182-1-14**] 2:33 a4/8/[**2185**] 07:49 pm [**2182-1-18**] 10:20 p [**2182-1-19**] 1:20 p [**2182-1-20**] 11:50 p [**2182-1-21**] 1:20 a [**2182-1-22**] 7:20 p 1//11/006 1:23 p [**2182-2-14**] 1:20 p [**2182-2-14**] 11:20 p [**2182-2-14**] 4:20 p wbc 3.5 hct 23.5 plt 95 cr 2.1 glucose 108 other labs: ca++:6.4 mg/dl, mg++:2.1 mg/dl, po4:2.7 mg/dl imaging: cxr [**2185-4-20**]: dictated report noted stable, widened mediastinum without evidence of congested pulmonary vasculature or pneumonia microbiology: pending ecg: nsr at 62, axis -30, lvh, peaked t waves, no st segment elevations assessment and plan 53 year old man with h/o aml s/p allo cord transplant complicated by chronic gvhd of the joints who now presents with worsening renal failure and hyperkalemia transitioned to the icu after code blue for brief episode of non-responsiveness. . # non-responsive episode - differential includes seizure, vagal episodes, hypoglycemia, arrhythmia in setting of hyperkalemia, medication toxicity from gabapentin in setting of evolving renal function. no report of seizure activity and no loss of bladder and no apparent post-ictal state. no neurologic deficit on exam. did received dose of cefepime on floor for concern of evolving sepsis despite current hemodynamic stability and absence of fever. - observe on tele overnight - consider eeg if he has recurrent episode of unresponsiveness - monitor fs qachs - pan culture, f/u cbc w/diff, discuss need for further abx w/ bmt in am - obtain head ct, non-con to rule out mass lesion - renally adjust all meds . # rising creatinine in setting of ckd. not yet acute change from most recent labs but has been steadly rising over past few months. urine sodium 48. fena not accurate in setting of chronic renal insufficiency as well as lasix use. fe urea also unlikely to be of much help given his ckd. etiology unclear. differential includes medication toxicity from immunosuppressants, gvhd of kidney, prerenal state w/ poor po from odynophagia. - trend post ivf bolus, f/u febun - send urine for sediment - consider repeat renal us, renal biopsy if does not improve overnight - adjust med dosing for change in creatinine clearance . # hyperkalemia. [**month (only) 60**] be med effect esp with recent cell-cept dose increase or lisinopril in setting of worsening renal failure vs. hemolysis/gi bleed and k reabsorption. - hold lisinopril - consider decreasing cell cept to [**telephone/fax (3) 8649**] as it was prior to 500 tid - treat w/ kayxalate, low potassium diet - check hemolysis labs . # aml s/p allo sct d+516. fairly recent bone marrow biopsy with female donor cells on chimerism. - continue cellcept/prednisone regimen, decrease as above . # anemia. chronic - monitor, transfuse for hct < 25 . # chronic gvhd including boop. on chronic steroids and cellcept -continue prednisone 20mg daily and use hydrocort stress dose steroids if hypotensive . # dysphagia. possible esophagitis from [**female first name (un) 188**](less likely given chronic use of vori) vs. gvhd infiltration vs. cmv esophagitis - plan for egd once leaves icu - trial of empiric nystatin swish and swallow - cmv viral load pending . # hypogammaglobulinemia. expected as a result of cord sct. - hold ivig while creatinine above baseline but would like to eventually dose w ivig . # sarcoid. . # fen: ivfs / replete lytes prn / regular diet . # ppx: ppi, bowel regimen . # access: 2 pivs . # code: full . # contact: wife [**name (ni) 263**] [**telephone/fax (1) 1421**] . # dispo: [**hospital unit name 44**] now icu care nutrition: glycemic control: regular insulin sliding scale, comments: home sliding scale and lines: prophylaxis: dvt: boots stress ulcer: ppi vap: comments: communication: family meeting held , icu consent signed comments: code status: full code disposition: icu ------ protected section ------ briefly, 53 y/o with aml h/o allo cord transplant, c/b gvhd + arthritis, boop, here after code called for unresponsiveness. apparently recent history notable for worsening odynophagia, reflux, fatigue, and joint pain; seen today for ivig in clinic and labs notable for cr 2.3, k 5.5 admitted for arf. on the bmt floor, was transitioning to the bed when he became briefly unresponsive by the time the code team arrived, vs were normal, responsive to verbal stimuli. ekg showed peaked ts and abg k of 6.5, treated for hyperk. two more episodes occurred where he closed his eyes and was not immediate arousable. in the icu, he reported chest discomfort and arm numbness. currently he denies any pain, dyspnea, n/v feels well. pmhx as above, plus h/o cardiomyopathy d/t chemo, sarcoid (inactive), dm, gerd, htn, disseminated candidiasis and nasal aspergillus, peripheral neuropathy. no allergies, but adverse reactions to ambisome, benadryl, flomax extensive med list reviewed, includes insulin, morphine, prednisone, vit d, mmf, prednisone on exam: afeb p84 bp 130 s/70s obese cushingoid nad a&ox3, perrl, eomi sl intention tremor rrr s1 s2 crackles l base o/w clear abd soft nt/nd tone wnl, mae labs: cbc initial ~stable vs prior: 5.3 / 29.3 / 101; f/u all counts down sl. 3.5 /23.5 / 95 chem-7: cr 2.3 from 2.0, k 5.5, bicarb 22 down from 26 at 630pm, abg: 7.38/39. k 6.5, na 132, lactate 1.7, glu 442 ca 6.4 from 8.4 cxr low lung vol, no acute change cxr nsr - ?peaked ts a/p: 53 y/o aml s/p all cord transplant, c/b gvhd, boop, ckd, admitted with mild worsening of renal function, transferred to icu after episode of unresponsiveness on the floor. syncope: unclear cause. ddx includes cardiogenic (eg arrhythmia, vagal), primary neurologic (sz, hypoglycemia). monitor on tele, cycle enzymes, consider re-echo, f/u fs glucose, head ct, consider neuro consult / eeg. renal failure: cr minimally increased from baseline ckd d/t atn/meds/other. ivf. hyperkalemia: 5.5 at admit, acute change at time of code unclear etiology unless acute acidosis, hemolysis did not receive k. agree with holding ace, hemolysis labs, holding lisinopril. hypocalcemia: also unclear nl on admit - sudden drop ?acidosis recheck. anemia: hct down recheck, gas. hemodynamically stable. ------ protected section addendum entered by:[**name (ni) 149**] [**last name (namepattern1) **], md on:[**2185-4-20**] 23:52 ------",1
199,"58 yo man c hx of alcoholic cirrhosis(grade 1 varices on nadolol, recent gi bleed)pt presented c dyspnea and worsening mental status for past few weeks. per family pt has not ate in a week and last drink was 2days ago. adm to [**hospital ward name 790**] 10 and then transferred to micu service [**5-12**] after ~ 50 cc brb emesis and drop in hct. cirrhosis of liver, alcoholic assessment: ascites. on octreotide and protonix gtt via piv. somnolent this am, oriented to person and place. ob + brown stool with yellow liq. abd leaking clear yellow liq from paracentesis site. action/response: am meds held this am d/t somnolence. team notified. pt more awake this afternoon, meds including lactulose give. swallowed water, and pills without coughing, but coughing after 30 cc s of lactulose. later in day, swallowing reassessed with water no coughing. pt given additional lactulose, without coughing but refusing full 60 cc dose. ocreotide gtt stopped @ 1100 d/t leaking iv. micu team notified. picc line placed, confirmed by cxr, ocreotide restarted @ 1500. hct drawn @ 1500. k 5.9 on am labs--ekg without ^ t s, repeat k 4.5. hct 28.4 (30). ciwa assessed, <10 throughout day. has visible tremors. abdomen cleansed, no sting barrier wipe applied to previous paracentesis site, fecal incont bag applied to site. plan: continue to monitor ciwa, iv valium for ciwa >10 (family reports adverse reaction to ativan). monitor bp/hr. octreotide/ptotonix gtt as ordered. lactulose as able. ? of micu team to place ngt if needed for lactulose administration. ? for endoscopy [**5-13**]. monitor drainage from paracentesis site. diabetes mellitus (dm), type i assessment: npo, bs s 160 s-170 action/response: given am dose of glargine 36 units, given dose of sliding scale humalog plan: continue to monitor bs. dose ss as ordered while npo. chronic obstructive pulmonary disease (copd, bronchitis, emphysema) with acute exacerbation assessment: sats 100% on 5l simple face mask. lungs with rhonchi, occ exp wheezing action: o2 weaned to ra with sats 90-92%. albuterol nebs q 6 hours response: decreased wheezing, sats acceptable plan: monitor sats, albuterol q6 hours.",1
200,"58 yo man c hx of alcoholic cirrhosis(grade 1 varices on nadolol, recent gi bleed)pt presented c dyspnea and worsening mental status for past few weeks. per family pt has not ate in a week and last drink was 2days ago. adm to [**hospital ward name 790**] 10 and then transferred to micu service [**5-12**] after ~ 50 cc brb emesis and drop in hct. cirrhosis of liver, alcoholic assessment: ascites. on octreotide and protonix gtt via piv. somnolent this am, oriented to person and place. ob + brown stool with yellow liq. abd leaking clear yellow liq from paracentesis site. action/response: am meds held this am d/t somnolence. team notified. pt more awake this afternoon, meds including lactulose give. swallowed water, and pills without coughing, but coughing after 30 cc s of lactulose. later in day, swallowing reassessed with water no coughing. pt given additional lactulose, without coughing but refusing full 60 cc dose. ocreotide gtt stopped @ 1100 d/t leaking iv. micu team notified. picc line placed, confirmed by cxr, ocreotide restarted @ 1500. hct drawn @ 1500. k 5.9 on am labs--ekg without ^ t s, repeat k 4.5. hct 28.4 (30). ciwa assessed, <10 throughout day. has visible tremors. abdomen cleansed, no sting barrier wipe applied to previous paracentesis site, fecal incont bag applied to site. plan: continue to monitor ciwa, iv valium for ciwa >10 (family reports adverse reaction to ativan). monitor bp/hr. octreotide/ptotonix gtt as ordered. lactulose as able. ? of micu team to place ngt if needed for lactulose administration. ? for endoscopy [**5-13**]. monitor drainage from paracentesis site. keep iv site and picc line site wrapped in kerlix d/t pulling out lines/ngt over night. diabetes mellitus (dm), type i assessment: npo, bs s 160 s-170 action/response: given am dose of glargine 36 units, given dose of sliding scale humalog plan: continue to monitor bs. dose ss as ordered while npo. chronic obstructive pulmonary disease (copd, bronchitis, emphysema) with acute exacerbation assessment: sats 100% on 5l simple face mask. lungs with rhonchi, occ exp wheezing action: o2 weaned to ra with sats 90-92%. albuterol nebs q 6 hours response: decreased wheezing, sats acceptable plan: monitor sats, albuterol q6 hours.",1
201,"58 yo man c hx of alcoholic cirrhosis(grade 1 varices on nadolol, recent gi bleed)pt presented c dyspnea and worsening mental status for past few weeks. per family pt has not ate in a week and last drink was 2days ago. adm to [**hospital ward name 790**] 10 and then transferred to micu service [**5-12**] after ~ 50 cc brb emesis and drop in hct. cirrhosis of liver, alcoholic assessment: ascites. on octreotide and protonix gtt via piv. somnolent this am, oriented to person and place. ob + brown stool with yellow liq. abd leaking clear yellow liq from paracentesis site. action/response: am meds held this am d/t somnolence. team notified. pt more awake this afternoon, meds including lactulose give. swallowed water, and pills without coughing, but coughing after 30 cc s of lactulose. later in day, swallowing reassessed with water no coughing. pt given additional lactulose, without coughing but refusing full 60 cc dose. ocreotide gtt stopped @ 1100 d/t leaking iv. micu team notified. picc line placed, confirmed by cxr, ocreotide restarted @ 1500. hct drawn @ 1500. k 5.9 on am labs--ekg without ^ t s, repeat k 4.5. hct 28.4 (30). ciwa assessed, <10 throughout day. has visible tremors. abdomen cleansed, no sting barrier wipe applied to previous paracentesis site, fecal incont bag applied to site. plan: continue to monitor ciwa, iv valium for ciwa >10 (family reports adverse reaction to ativan). monitor bp/hr. octreotide/ptotonix gtt as ordered. lactulose as able. ? of micu team to place ngt if needed for lactulose administration. ? for endoscopy [**5-13**]. monitor drainage from paracentesis site. keep iv site and picc line site wrapped in kerlix d/t pulling out lines/ngt over night. diabetes mellitus (dm), type i assessment: npo, bs s 160 s-170 action/response: given am dose of glargine 36 units, given dose of sliding scale humalog plan: continue to monitor bs. dose ss as ordered while npo. chronic obstructive pulmonary disease (copd, bronchitis, emphysema) with acute exacerbation assessment: sats 100% on 5l simple face mask. lungs with rhonchi, occ exp wheezing action: o2 weaned to ra with sats 90-92%. albuterol nebs q 6 hours response: decreased wheezing, sats acceptable plan: monitor sats, albuterol q6 hours.",1
202,"58 yo man c hx of alcoholic cirrhosis(grade 1 varices on nadolol, recent gi bleed)pt presented c dyspnea and worsening mental status for past few weeks. per family pt has not ate in a week and last drink was 2days ago. adm to [**hospital ward name 790**] 10 and then transferred to micu service [**5-12**] after ~ 50 cc brb emesis and drop in hct. cirrhosis of liver, alcoholic assessment: ascites. on octreotide and protonix gtt via picc. oriented only to self this am, but following commands better than yesterday and less tremor. ciwa 12. action/response: receiving lactulose q 4 hours. brown/black liq stool, ob +. gi fellow and micu team notified. hct 29 (30). set up to undergo bedside endoscopy, when pt began vomiting brb (~ 200cc s). decision made to electively intubate, [**last name (un) 4601**] tube placed, trauma tlc cath placed. ~ 350 cc brb from [**last name (un) 4601**] tube. gastric balloon inflated by gi. pt received a total of 2 units prbc and 2 units of ffp. repeat hct 28.4 plan: continue to monitor ciwa, iv valium for ciwa >10 (family reports adverse reaction to ativan). monitor bp/hr. octreotide/ptotonix gtt as ordered. lactulose as able. ? of micu team to place ngt if needed for lactulose administration. ? for endoscopy [**5-13**]. monitor drainage from paracentesis site. keep iv site and picc line site wrapped in kerlix d/t pulling out lines/ngt over night. diabetes mellitus (dm), type i assessment: npo, bs s 140 s-160 action/response: given am dose of glargine 36 units, given dose of sliding scale humalog plan: continue to monitor bs. dose ss as ordered while npo. chronic obstructive pulmonary disease (copd, bronchitis, emphysema) with acute exacerbation assessment: sats 90-91% ra this am. lungs with few rhonchi. action: pt placed on 5l np for endoscopy with sats 99%. received etomidate/succ for intubation, received a total of 13mg versed in 2 mg increments and a total of 150 mcg fentanyl in 50 mcg increments during [**last name (un) 4601**], tlc, a-line placement. now on a propofol gtt. once intubated lungs with few wheezes, resolved without treatment. remains on ac 500-16 breathing [**1-29**] over the vent, with fio2 weaned from 100% to 60%. ets response: plan: monitor abg, sats. monitor lung sounds.",1
203,"please note that 0300 labs drawn from picc and then redrawn at 0400 from venipuncture /peripheral stick alteration in nutrition assessment: pt w/ very poor po intake, refused po meds and sips of liquid. unable to swallow meds crushed in applesauce .overall very fragile and weak. pt has refused placement of ngt or dophoff . action: standard tpn ordered with amino acids and hung at midnoc. response: no adverse reaction noted plan: team will need to order tpn altered mental status (not delirium) assessment: ms waxes and wanes oriented x 1 oriented to self only overnight. speech continues to be very soft and garbled , difficult to understand. pt believed he was at home when asked where he was. unaware of season of year or the year. action: pt given morphine 1 mg at 2300 and 0500 for generalized back pain with activity. pt refusing all mouth care from me this evening, but has been cooperative with back care and turning. pt really having trouble getting thoughts out verbally and becomes frustrated response: . frequent reorientation. pt a bit quieter and calmer now- as compared to previous shift plan: cont to reorient, provide quiet/calm environment. pneumonia, other assessment: patient with unilateral multi-lobar pulmonary infiltrate. ls rhonchorous throughout. rr teens to 30s, weak/congested non-productive cough. received pt on 4l via n/c. very difficult to get a good o2 sat on pt. fluctuating between 87-96% on o2. sat s dropped to consistently low 80 s at 0500 and pt placed on 35% fio2 face tent. sat s increased within 10 minutes to 90-92% action: given flagyl and vanco. response: no change in respiratory status. cxr slightly improved. after 6am dose lopressor, hr decreased to 50-70 s and decrease in ectopy noted. pt able to be weaned off face tent. plan: cont w/ antibiotics, ? d/c to ltac facility. atrial fibrillation (afib) assessment: [**name (ni) **] pt has been in ventricular bijeminy, sinus arrhythmia and nsr with multi pvc s and pac s. pt poorly tolerates fast or abnormal rhythm. pt seems to desaturtate when in afib or sinus arrhythmia. action: continue on lopressor 7.5mg q6hr response: monitor plan: continue iv lopressor",0
204,"chief complaint: s/p pea arrest during echo while admitted for presumed copd admission to [**hospital1 **] [**location (un) 1415**]. to [**location (un) 1415**] with sob, cough, thought to be copd. declined bipap. pea arrest at noon on [**1-1**]. given atropine, epinephrine, intubation and crp with restoration of circulation. on levophed. ct torso showed spinal fracture at t11 with hemorrhage into canal. ct head clear despite right ear bleeding. hypothesis is kyphosis/as with fusion, lying flat and crp -> fracture. 24 hour events: - spoke to anesthesia about surgery (that ortho. spine agreed to). they feel risk very great, but likely less if wait after cardiac arrest. therefore will be important to assess functional status, clearly understand functional status prior to event, know what cortical function is like, discuss with daughter (anesthesia happy to talk to her in a.m. - just call anesthetist on service in a.m. in or - x43000 when daughter here or know that she's available). - no bowel movements - will be repeat echo this a.m. - need to discuss plan with ortho spine and anesthetics. allergies: penicillins hives; sulfonamides unknown; bactrim (oral) (sulfamethoxazole/trimethoprim) rash; vancomycin rash; last dose of antibiotics: ceftriaxone - [**2120-1-2**] 08:12 pm levofloxacin - [**2120-1-2**] 09:59 pm piperacillin - [**2120-1-3**] 12:00 am infusions: midazolam (versed) - 2 mg/hour fentanyl (concentrate) - 150 mcg/hour phenylephrine - 0.5 mcg/kg/min other icu medications: propofol - [**2120-1-2**] 02:20 pm fentanyl - [**2120-1-2**] 04:30 pm midazolam (versed) - [**2120-1-2**] 04:30 pm heparin sodium (prophylaxis) - [**2120-1-2**] 10:00 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2120-1-3**] 06:56 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.6 c (97.9 tcurrent: 36.6 c (97.9 hr: 74 (68 - 88) bpm bp: 98/45(64) {70/42(56) - 186/93(130)} mmhg rr: 20 (19 - 28) insp/min spo2: 100% heart rhythm: sr (sinus rhythm) cvp: 10 (8 - 18)mmhg total in: 1,785 ml 348 ml po: tf: ivf: 1,785 ml 348 ml blood products: total out: 259 ml 365 ml urine: 259 ml 365 ml ng: stool: drains: balance: 1,526 ml -17 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 400 (380 - 400) ml rr (set): 20 rr (spontaneous): 0 peep: 10 cmh2o fio2: 40% rsbi deferred: peep > 10 pip: 44 cmh2o plateau: 28 cmh2o compliance: 33.3 cmh2o/ml spo2: 100% abg: 7.35/55/145/30/3 ve: 8.6 l/min pao2 / fio2: 363 physical examination general appearance: very obese, lying on back, intubated on assist eyes / conjunctiva: perrl head, ears, nose, throat: normocephalic, endotracheal tube, no further right ear bleeding. cardiovascular: very distant heart sounds peripheral vascular: dp not palpable, radial 1+. extremities: right hand and left foot cool; left foot and right arm warm. right arm erythematous. respiratory / chest: expansion: symmetric, breath sounds: wheeze throughout. did not auscultate back abdominal: soft, bowel sounds present, obese, non-tender skin: not assessed neurologic: responds to loud verbal stimuli, touching chest, movement: movement of neck and opening of eyes in response to verbal stimuli and tactile stimulation of chest. sedated. labs / radiology 335 k/ul 9.6 g/dl 122 0.7 mg/dl 30 meq/l 4.1 meq/l 36 mg/dl 108 meq/l 144 meq/l 29.7 % 19.9 k/ul [image002.jpg] abg: 7.35 55 145 32 3 ck 825 mb 21 mbi 3.1 2.5 tt 0.04 (from 0.07 at arrival) [**2120-1-2**] 12:46 pm [**2120-1-2**] 02:32 pm [**2120-1-2**] 07:21 pm [**2120-1-2**] 10:00 pm [**2120-1-3**] 03:43 am [**2120-1-3**] 04:00 am [**2120-1-3**] 04:22 am wbc 11.3 19.9 hct 28.7 30.1 29.7 plt 205 335 cr 0.7 0.7 tropt 0.07 0.04 0.04 tco2 33 32 glucose 113 110 124 122 other labs: pt / ptt / inr:13.1/30.8/1.1, ck / ckmb / troponin-t:825/21/0.04, alt / ast:31/46, alk phos / t bili:61/0.2, differential-neuts:83.0 %, lymph:12.7 %, mono:4.1 %, eos:0.1 %, lactic acid:1.1 mmol/l, ldh:215 iu/l, ca++:8.3 mg/dl, mg++:2.1 mg/dl, po4:2.5 mg/dl micro: gram stain endotracheal sputum [**10-29**] pmns, 3+ gnrs, 1+ budding yeast legionella antigen negative blood cultures pending. imaging: ct torso [**2120-1-1**]: 2. massive disruption at the t11 level with distraction, hemorrhage into the central canal, massive angulation and vertebral body destruction. vertebral body destruction ivovles essentially the entire t11 body and the inferior aspect of t10. there is extensive soft tissue pathology here. while much of this is of high attenuation the suggestion of hemorrhage, and given the underlying bony ankylosis trauam is thought a possible diagnosis, infection and or pathological fracture secondary to tumor are myeloma are not excluded. 2. there is no evidence of primary or secondary malignancy elsewhere. there are no findings suggestive of dissection or acute aortic pathology. there are innumerable pulmonary nodules, many of which are ground glass in nature, possible infectious but non-specific. echocardiogram [**2120-1-1**]: the left atrial volume is mildly increased. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is mildly depressed (lvef= 50 %). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are moderately thickened. there is moderate aortic valve stenosis (valve area 1.0-1.2cm2). no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. ct head [**2120-1-1**]: the ventricles and sulci are normal in caliber and configuration. remnant contrast is seen within the venous and arterial system within the brain likely from prior done ct torso. this lowers the sensitivity of the current study for small infarcts. however no large infarcts, bleeds, or other acute processes are present. no fractures are present. the mastoid air cells and sinuses are well-aerated. an et tube is seen in the oral cavity. cxr [**2120-1-1**]: an endotracheal tube has been positioned with the tip about 5 cm above the carina. there is diffuse density overlying the right base but this appears to be artificial. the lungs appear clear with normal vascularity and the cardiac size is within normal limits. ecg: ekg [**2119-12-30**]: sinus tachycardia at 107, normal axis, q waves in ii, iii, avf, no st slevation or depression. assessment and plan this is a 76 year old female with a history of copd on home oxygen, moderate to severe aortic stenosis and diastolic heart failure who presented to [**location (un) 1415**] on [**2119-12-30**] with progressive dyspnea on exertion and cough productive of clear sputum transferred here after pea arrest with evidence of unstable t11 fracture. cord injury very likely, very poor surgical candidate, so will need to discuss this further with ortho, anesthetics and family. otherwise treat respiratory failure/copd. unstable t11 fracture spine is currently unstable. cord involvement likely and recovery unlikely. therefore intervention to improve stability and possibly to prevent pain associated with instability. currently not withdrawing to painful stimuli in the lower extremities. ortho. spine happy to operate. need to evaluate and discuss further with anesthetics and ortho. possible that delaying may improve prognosis with respect to anesthesia/procedure. not clear that patient will tolerate lying prone for procedure. mri not possible due to girth, so evaluation of spinal injury will have to be functional. - consider mri if possible - d/w anesthesia and ortho spine then - d/w family whether or not operative management would be within the patient's goals of care - log roll precautions shortness of breath/hypercarbic respiratory failure patient with known copd at baseline on home oxygen. she initially presented with worsening dyspnea and cough. she quickly progressed to hypercarbic respiratory failure. cxr have been unremarkable but ct chest with multiple small nodules which could be infectious in origin. concern for atypical pathogens given recurrent steroid use. legionella is negative, therefore can stop levofloxacin coverage. - continue solumedrol 80 mg iv q8h - continue albuterol and ipratropium - continue mechanical ventilation for now pea arrest enzymes now trending down. most likely etiology is hypercarbia/hypoxia given abg at the time of her arrest. unclear how long she was pulseless but she had return of spontaneous circulation with one round of epinephrine and atropine. relatively [**name2 (ni) 11259**] enzymes leak consistent with relatively brief event. there are no ekgs from the time of the arrest in her paperwork. she had a ct torso which showed no evidence of pulmonary embolism. she was not cooled post-arrest. will evaluate cardiac function. - echo this a.m. hypotension differential diagnosis is broad and includes sepsis, cardiogenic shock, obstructive shock, volume depletion, decreased preload secondary to mechanical ventilation and others. patient is (still about) 5.5 liters positive since her cardiac arrest yesterday. - echocardiogram pending - fluid challenge now for resuscitation goals of cvp > 10, uop > 30 cc/hr, map > 60 - continue fentanyl and versed (instead of propofol) - check mixed venous oxygen saturation - phenylephrine for pressor as needed leukocytosis contribution by pea arrest, steroids, spinal fracture, but still need to be sensitive to history of mrsa basteremia. will hold off on vancomycin for now given previous adverse reaction (consider linezolid if febrile or others signs of sepsis). - follow urinary tract infection patient with ciprofloxacin resistent urinary tract infection on [**2119-12-31**]. now on ceftriaxone day [**2-11**]. - continue ceftriaxone day [**2-11**] anemia hematocrit 28 on arrival from 36 on [**2119-12-30**]. now stable at 29. likely dilutional in the setting of fluid resuscitation post-arrest. also a report of mild gastrointesinal bleeding in the setting of lovenox administration. - maintain active type and screen - trend hematocrit - guaiac stools - transfusion goal > 25 in periarrest period right ear bleeding possible injury to tympanic membrane during resuscitation in context of anticoagulation. normal head ct at [**location (un) 1415**]. - otoscopy fen: normal saline boluses for resuscitation parameters as above, replete electrolytes, has ngt for tube feeds. prophylaxis: subcutaneous heparin access: right ij placed, left radial arterial line communication: daughters [**name (ni) 755**] [**telephone/fax (1) 11255**], [**name2 (ni) 378**] [**telephone/fax (1) 11256**] code: full (discussed with patient) disposition: icu pending clinical improvement icu care nutrition: glycemic control: lines: 20 gauge - [**2120-1-2**] 12:30 pm arterial line - [**2120-1-2**] 01:30 pm multi lumen - [**2120-1-2**] 03:00 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: full code disposition: ------ protected section ------ micu attending addendum i saw and examined the patient, and was physically present with the icu team for the key portions of the services provided. i agree with the note above, including the assessment and plan. i would emphasize and add the following points: 76f severe copd, mod as, morbid obesity, diastolic chf p/w progressive doe and cough, which progressed over the course of hospitalization at [**location (un) 1415**]. pea arrest in the setting of acute hypercarbia c/b t11 fx. remains on pressors. exam notable for tm 99.2 bp 136/76 hr 72 rr 22 with sat 99 on vac 400x20 0.4 10 7.35/55/145. labs notable for wbc 19k, hct 30, k+ 4.1, hco3 30, cr 0.7. cxr with hyperlucency, flat diaphragms. agree with plan to manage hypercarbic respiratory failure / pea arrest with transition to psv, will wean fio2 for sat 90% and continue steroids / abx for component of copd flare / infection. at this point we can d/c levo, as legionella negative and suspicion for atypical infection is low. post arrest, will trend enzymes, check echo / ekg and follow serial exams. ongoing hypotension / autonomic lability may be due to peep, sedation, spinal injury or infection; will check cvo2 and echo and treat uti+/- pna. for spine fx, d/w anesthesia, surgery and family re plan going forward w/r/t surgery for stabilization. start tfs, comunication with daughter. remainder of plan as outlined above. patient is critically ill total time: 35 min ------ protected section addendum entered by:[**name (ni) 34**] [**last name (namepattern1) 33**], md on:[**2120-1-3**] 03:52 pm ------",1
205,"alteration in nutrition assessment: pt w/ very poor po intake, refused po meds and sips of liquid. unable to swallow meds crushed in applesauce .overall very fragile and weak. pt has refused placement of ngt or dophoff . action: standard tpn ordered with amino acids and hung at midnoc. response: no adverse reaction noted plan: team will need to order tpn altered mental status (not delirium) assessment: ms waxes and wanes oriented x 1 oriented to self only overnight. speech continues to be very soft and garbled , difficult to understand. pt believed he was at home when asked where he was. unaware of season of year or the year. action: pt given morphine 1 mg at 2300 and 0500 for generalized back pain with acivity. pt refusing all mouthcare from me this evening, but has been cooperative with back care and turning. response: . frequent reorientation. pt a bit quieter and calmer now- as compared to previous shift plan: cont to reorient, provide quiet/calm environment. pneumonia, other assessment: patient with unilateral multi-lobar pulmonary infiltrate. ls rhonchorous throughout. rr teens to 30s, weak/congested non-productive cough. received pt on 4l via n/c. very difficult to get a good o2 sat on pt. fluctuating between 87-96% on o2. sat s dropped to consistently low 80 s at 0500 and pt placed on 35% fio2 face tent. sat s increased within 10 minutes to 90-92% action: given flagyl and vanco. pt oob to chair w/ [**doctor last name 770**] lift. response: no change in respiratory status. cxr slightly improved. plan: cont w/ antibiotics, ? d/c to ltac facility. atrial fibrillation (afib) assessment: [**name (ni) **] pt has been in ventricular bijeminy, sinus arrhythmia and nsr with multi pvc s and pac action: continue on lopressor 7.5mg q6hr response: plan:",0
206,"chief complaint: s/p pea arrest during echo while admitted for presumed copd admission to [**hospital1 **] [**location (un) 1415**]. to [**location (un) 1415**] with sob, cough, thought to be copd. declined bipap. pea arrest at noon on [**1-1**]. given atropine, epinephrine, intubation and crp with restoration of circulation. on levophed. ct torso showed spinal fracture at t11 with hemorrhage into canal. ct head clear despite right ear bleeding. hypothesis is kyphosis/as with fusion, lying flat and crp -> fracture. 24 hour events: - spoke to anesthesia about surgery (that ortho. spine agreed to). they feel risk very great, but likely less if wait after cardiac arrest. therefore will be important to assess functional status, clearly understand functional status prior to event, know what cortical function is like, discuss with daughter (anesthesia happy to talk to her in a.m. - just call anesthetist on service in a.m. in or - x43000 when daughter here or know that she's available). - no bowel movements - will be repeat echo this a.m. - need to discuss plan with ortho spine and anesthetics. allergies: penicillins hives; sulfonamides unknown; bactrim (oral) (sulfamethoxazole/trimethoprim) rash; vancomycin rash; last dose of antibiotics: ceftriaxone - [**2120-1-2**] 08:12 pm levofloxacin - [**2120-1-2**] 09:59 pm piperacillin - [**2120-1-3**] 12:00 am infusions: midazolam (versed) - 2 mg/hour fentanyl (concentrate) - 150 mcg/hour phenylephrine - 0.5 mcg/kg/min other icu medications: propofol - [**2120-1-2**] 02:20 pm fentanyl - [**2120-1-2**] 04:30 pm midazolam (versed) - [**2120-1-2**] 04:30 pm heparin sodium (prophylaxis) - [**2120-1-2**] 10:00 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2120-1-3**] 06:56 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.6 c (97.9 tcurrent: 36.6 c (97.9 hr: 74 (68 - 88) bpm bp: 98/45(64) {70/42(56) - 186/93(130)} mmhg rr: 20 (19 - 28) insp/min spo2: 100% heart rhythm: sr (sinus rhythm) cvp: 10 (8 - 18)mmhg total in: 1,785 ml 348 ml po: tf: ivf: 1,785 ml 348 ml blood products: total out: 259 ml 365 ml urine: 259 ml 365 ml ng: stool: drains: balance: 1,526 ml -17 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 400 (380 - 400) ml rr (set): 20 rr (spontaneous): 0 peep: 10 cmh2o fio2: 40% rsbi deferred: peep > 10 pip: 44 cmh2o plateau: 28 cmh2o compliance: 33.3 cmh2o/ml spo2: 100% abg: 7.35/55/145/30/3 ve: 8.6 l/min pao2 / fio2: 363 physical examination general appearance: very obese, lying on back, intubated on assist eyes / conjunctiva: perrl head, ears, nose, throat: normocephalic, endotracheal tube, no further right ear bleeding. cardiovascular: very distant heart sounds peripheral vascular: dp not palpable, radial 1+. extremities: right hand and left foot cool; left foot and right arm warm. right arm erythematous. respiratory / chest: expansion: symmetric, breath sounds: wheeze throughout. did not auscultate back abdominal: soft, bowel sounds present, obese, non-tender skin: not assessed neurologic: responds to loud verbal stimuli, touching chest, movement: movement of neck and opening of eyes in response to verbal stimuli and tactile stimulation of chest. sedated. labs / radiology 335 k/ul 9.6 g/dl 122 0.7 mg/dl 30 meq/l 4.1 meq/l 36 mg/dl 108 meq/l 144 meq/l 29.7 % 19.9 k/ul [image002.jpg] abg: 7.35 55 145 32 3 ck 825 mb 21 mbi 3.1 2.5 tt 0.04 (from 0.07 at arrival) [**2120-1-2**] 12:46 pm [**2120-1-2**] 02:32 pm [**2120-1-2**] 07:21 pm [**2120-1-2**] 10:00 pm [**2120-1-3**] 03:43 am [**2120-1-3**] 04:00 am [**2120-1-3**] 04:22 am wbc 11.3 19.9 hct 28.7 30.1 29.7 plt 205 335 cr 0.7 0.7 tropt 0.07 0.04 0.04 tco2 33 32 glucose 113 110 124 122 other labs: pt / ptt / inr:13.1/30.8/1.1, ck / ckmb / troponin-t:825/21/0.04, alt / ast:31/46, alk phos / t bili:61/0.2, differential-neuts:83.0 %, lymph:12.7 %, mono:4.1 %, eos:0.1 %, lactic acid:1.1 mmol/l, ldh:215 iu/l, ca++:8.3 mg/dl, mg++:2.1 mg/dl, po4:2.5 mg/dl micro: gram stain endotracheal sputum [**10-29**] pmns, 3+ gnrs, 1+ budding yeast legionella antigen negative blood cultures pending. imaging: ct torso [**2120-1-1**]: 2. massive disruption at the t11 level with distraction, hemorrhage into the central canal, massive angulation and vertebral body destruction. vertebral body destruction ivovles essentially the entire t11 body and the inferior aspect of t10. there is extensive soft tissue pathology here. while much of this is of high attenuation the suggestion of hemorrhage, and given the underlying bony ankylosis trauam is thought a possible diagnosis, infection and or pathological fracture secondary to tumor are myeloma are not excluded. 2. there is no evidence of primary or secondary malignancy elsewhere. there are no findings suggestive of dissection or acute aortic pathology. there are innumerable pulmonary nodules, many of which are ground glass in nature, possible infectious but non-specific. echocardiogram [**2120-1-1**]: the left atrial volume is mildly increased. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is mildly depressed (lvef= 50 %). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are moderately thickened. there is moderate aortic valve stenosis (valve area 1.0-1.2cm2). no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is no pericardial effusion. ct head [**2120-1-1**]: the ventricles and sulci are normal in caliber and configuration. remnant contrast is seen within the venous and arterial system within the brain likely from prior done ct torso. this lowers the sensitivity of the current study for small infarcts. however no large infarcts, bleeds, or other acute processes are present. no fractures are present. the mastoid air cells and sinuses are well-aerated. an et tube is seen in the oral cavity. cxr [**2120-1-1**]: an endotracheal tube has been positioned with the tip about 5 cm above the carina. there is diffuse density overlying the right base but this appears to be artificial. the lungs appear clear with normal vascularity and the cardiac size is within normal limits. ecg: ekg [**2119-12-30**]: sinus tachycardia at 107, normal axis, q waves in ii, iii, avf, no st slevation or depression. assessment and plan this is a 76 year old female with a history of copd on home oxygen, moderate to severe aortic stenosis and diastolic heart failure who presented to [**location (un) 1415**] on [**2119-12-30**] with progressive dyspnea on exertion and cough productive of clear sputum transferred here after pea arrest with evidence of unstable t11 fracture. cord injury very likely, very poor surgical candidate, so will need to discuss this further with ortho, anesthetics and family. otherwise treat respiratory failure/copd. unstable t11 fracture spine is currently unstable. cord involvement likely and recovery unlikely. therefore intervention to improve stability and possibly to prevent pain associated with instability. currently not withdrawing to painful stimuli in the lower extremities. ortho. spine happy to operate. need to evaluate and discuss further with anesthetics and ortho. possible that delaying may improve prognosis with respect to anesthesia/procedure. not clear that patient will tolerate lying prone for procedure. mri not possible due to girth, so evaluation of spinal injury will have to be functional. - consider mri if possible - d/w anesthesia and ortho spine then - d/w family whether or not operative management would be within the patient's goals of care - log roll precautions shortness of breath/hypercarbic respiratory failure patient with known copd at baseline on home oxygen. she initially presented with worsening dyspnea and cough. she quickly progressed to hypercarbic respiratory failure. cxr have been unremarkable but ct chest with multiple small nodules which could be infectious in origin. concern for atypical pathogens given recurrent steroid use. legionella is negative, therefore can stop levofloxacin coverage. - continue solumedrol 80 mg iv q8h - continue albuterol and ipratropium - continue mechanical ventilation for now pea arrest enzymes now trending down. most likely etiology is hypercarbia/hypoxia given abg at the time of her arrest. unclear how long she was pulseless but she had return of spontaneous circulation with one round of epinephrine and atropine. relatively [**name2 (ni) 11259**] enzymes leak consistent with relatively brief event. there are no ekgs from the time of the arrest in her paperwork. she had a ct torso which showed no evidence of pulmonary embolism. she was not cooled post-arrest. will evaluate cardiac function. - echo this a.m. hypotension differential diagnosis is broad and includes sepsis, cardiogenic shock, obstructive shock, volume depletion, decreased preload secondary to mechanical ventilation and others. patient is (still about) 5.5 liters positive since her cardiac arrest yesterday. - echocardiogram pending - fluid challenge now for resuscitation goals of cvp > 10, uop > 30 cc/hr, map > 60 - continue fentanyl and versed (instead of propofol) - check mixed venous oxygen saturation - phenylephrine for pressor as needed leukocytosis contribution by pea arrest, steroids, spinal fracture, but still need to be sensitive to history of mrsa basteremia. will hold off on vancomycin for now given previous adverse reaction (consider linezolid if febrile or others signs of sepsis). - follow urinary tract infection patient with ciprofloxacin resistent urinary tract infection on [**2119-12-31**]. now on ceftriaxone day [**2-11**]. - continue ceftriaxone day [**2-11**] anemia hematocrit 28 on arrival from 36 on [**2119-12-30**]. now stable at 29. likely dilutional in the setting of fluid resuscitation post-arrest. also a report of mild gastrointesinal bleeding in the setting of lovenox administration. - maintain active type and screen - trend hematocrit - guaiac stools - transfusion goal > 25 in periarrest period right ear bleeding possible injury to tympanic membrane during resuscitation in context of anticoagulation. normal head ct at [**location (un) 1415**]. - otoscopy fen: normal saline boluses for resuscitation parameters as above, replete electrolytes, has ngt for tube feeds. prophylaxis: subcutaneous heparin access: right ij placed, left radial arterial line communication: daughters [**name (ni) 755**] [**telephone/fax (1) 11255**], [**name2 (ni) 378**] [**telephone/fax (1) 11256**] code: full (discussed with patient) disposition: icu pending clinical improvement icu care nutrition: glycemic control: lines: 20 gauge - [**2120-1-2**] 12:30 pm arterial line - [**2120-1-2**] 01:30 pm multi lumen - [**2120-1-2**] 03:00 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: full code disposition:",1
207,"chief complaint: pea arrest at [**location (un) 1415**] in context copd flare, successful ressusciation, no broken spine, bacteremia. 24 hour events: trans esophageal echo - at [**2120-1-3**] 10:22 am echo: overall lv and rv sys. fxn likely normal, mod. as, no ai, 1+ mr, mod. pa htn pan culture - at [**2120-1-3**] 08:24 pm - spiked to 100.8 @ 20:00, blood + sputum + urine cx sent, started on cefepime + cipro + linezolid (note exfoliative rash with vanco) - spoke with family re: course of events and extent of injuries, family agreed that surgery is very high risk and should not be attempted at this time, but may be revisited at a later date - orthospine: willing to take patient to or if requested, but communicate the risk involved - failed trial of psv now back on ac - blood cx gpc in clusters / sputum gnr - tube feeds started @ mn - shoulder contusions and pain on movement, palpation. allergies: penicillins hives; sulfonamides unknown; bactrim (oral) (sulfamethoxazole/trimethoprim) rash; vancomycin rash; last dose of antibiotics: levofloxacin - [**2120-1-2**] 09:59 pm piperacillin - [**2120-1-3**] 12:00 am ceftriaxone - [**2120-1-3**] 08:25 pm cefipime - [**2120-1-3**] 11:00 pm ciprofloxacin - [**2120-1-3**] 11:30 pm linezolid - [**2120-1-4**] 12:06 am infusions: fentanyl (concentrate) - 150 mcg/hour midazolam (versed) - 1 mg/hour other icu medications: heparin sodium (prophylaxis) - [**2120-1-3**] 02:26 pm pantoprazole (protonix) - [**2120-1-3**] 08:25 pm fentanyl - [**2120-1-4**] 07:00 am other medications: changes to medical and family history: no further. review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2120-1-4**] 07:49 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 38.2 c (100.8 tcurrent: 37.7 c (99.8 hr: 85 (69 - 104) bpm bp: 79/47(60) {79/43(60) - 130/59(85)} mmhg rr: 19 (11 - 26) insp/min spo2: 97% heart rhythm: sr (sinus rhythm) height: 69 inch cvp: 7 (7 - 12)mmhg co/ci (fick): (-3.1 l/min) / (-1.2 l/min/m2) mixed venous o2% sat: 76 - 180 total in: 1,407 ml 1,172 ml po: tf: 62 ml 154 ml ivf: 1,345 ml 1,019 ml blood products: total out: 1,065 ml 480 ml urine: 1,065 ml 480 ml ng: stool: drains: balance: 342 ml 692 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 400 (400 - 400) ml vt (spontaneous): 0 (0 - 615) ml ps : 20 cmh2o rr (set): 18 rr (spontaneous): 0 peep: 10 cmh2o fio2: 30% rsbi deferred: peep > 10 pip: 39 cmh2o plateau: 23 cmh2o compliance: 50 cmh2o/ml spo2: 97% abg: 7.31/65/77/32/3 ve: 7.8 l/min pao2 / fio2: 257 physical examination general appearance: overweight / obese eyes / conjunctiva: perrl, conjunctiva not pale, no scleral icterus edema head, ears, nose, throat: normocephalic, endotracheal tube, ng tube cardiovascular: (s1: normal), (s2: normal, distant), no(t) s3, no(t) s4, no(t) rub, (murmur: no(t) systolic, no(t) diastolic) peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) respiratory / chest: (expansion: symmetric), (breath sounds: clear : , wheezes : ) abdominal: soft, non-tender, bowel sounds present extremities: right lower extremity edema: trace, left lower extremity edema: trace, no(t) cyanosis, no(t) clubbing musculoskeletal: no(t) muscle wasting, unable to stand skin: not assessed, no(t) rash: , no(t) jaundice neurologic: responds to: not assessed, movement: not assessed, sedated, tone: not assessed labs / radiology 279 k/ul 9.0 g/dl 151 mg/dl 0.7 mg/dl 32 meq/l 4.6 meq/l 41 mg/dl 109 meq/l 144 meq/l 28.5 % 18.5 k/ul [image002.jpg] [**2120-1-2**] 02:32 pm [**2120-1-2**] 07:21 pm [**2120-1-2**] 10:00 pm [**2120-1-3**] 03:43 am [**2120-1-3**] 04:00 am [**2120-1-3**] 04:22 am [**2120-1-3**] 11:08 am [**2120-1-3**] 06:30 pm [**2120-1-4**] 04:16 am [**2120-1-4**] 04:48 am wbc 19.9 18.5 hct 30.1 29.7 28.5 plt 335 279 cr 0.7 0.7 tropt 0.04 0.04 tco2 33 32 33 33 34 glucose 110 124 122 151 other labs: pt / ptt / inr:13.1/30.8/1.1, ck / ckmb / troponin-t:825/21/0.04, alt / ast:31/46, alk phos / t bili:61/0.2, differential-neuts:83.0 %, lymph:12.7 %, mono:4.1 %, eos:0.1 %, lactic acid:0.9 mmol/l, ldh:215 iu/l, ca++:8.4 mg/dl, mg++:2.4 mg/dl, po4:2.6 mg/dl imaging: cxr pending/pending read. echo [**1-3**] the left atrium is elongated. left ventricular wall thicknesses are normal. 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 probably normal. right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve is not well seen. there is at least moderate aortic stenosis but doppler data are technically suboptimal for estimation of aortic valve area. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of [**2117-12-22**], the aortic valve gradient is now higher. microbiology: blood culture, routine (preliminary): gram positive coccus(cocci). in clusters. anaerobic bottle gram stain (final [**2120-1-3**]): gram positive cocci in clusters. reported by phone to [**first name4 (namepattern1) 11271**] [**last name (namepattern1) **] at 10:00pm on [**2120-1-3**]. mrsa screen (final [**2120-1-3**]): positive for methicillin resistant staph aureus. [**2120-1-2**] 1:16 pm sputum site: endotracheal source: endotracheal. gram stain (final [**2120-1-2**]): [**10-29**] pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): budding yeast. respiratory culture (preliminary): further incubation required to determine the presence or absence of commensal respiratory flora. gram negative rod(s). moderate growth. urine negative for legionella serogroup 1 antigen. sputum gram stain (final [**2120-1-3**]): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. ecg: none. assessment and plan hypotension (not shock) respiratory failure, acute (not ards/[**doctor last name **]) trauma, s/p this is a 76 year old female with a history of copd on home oxygen, moderate to severe aortic stenosis and diastolic heart failure who presented to [**location (un) 1415**] on [**2119-12-30**] with progressive dyspnea on exertion and cough productive of clear sputum transferred here after pea arrest with evidence of unstable t11 fracture. cord injury very likely, very poor surgical candidate, so will need to discuss this further with ortho, anesthetics and family. otherwise treat respiratory failure/copd. shortness of breath/hypercarbic respiratory failure patient with known copd at baseline on home oxygen. transition to psv, will wean fio2 for sat 90% and continue steroids / abx for component of copd flare / infection. cxr have been unremarkable but ct chest with multiple small nodules (seeding?) which could be infectious in origin. - continue cmv - continue solumedrol 80 mg iv q8h - continue albuterol and ipratropium autonomic lability and hypotension interesting unknown etiology. dm, cmv, pain (some not transmitted to forebrain/at spinal level/brainstem), spinal injury, sepsis, uti, pna, other contributors. - treat underlying causes, infection, pain. - fluid challenge now for resuscitation goals of cvp > 10, uop > 30 cc/hr, map > 60 - continue fentanyl and versed (instead of propofol) - check mixed venous oxygen saturation - phenylephrine for pressor as needed pea arrest enzymes now trending down. echo not remarkable. escaped serious myocardial damage. typical cad management. unstable t11 fracture family and ortho/anesthetics agreed yesterday to leave this for now, pending improved stability for surgery. leukocytosis contribution by pea arrest, uti, steroids, spinal fracture, but still need to be sensitive to history of mrsa bacteremia, now positive blood culture, possible pna and mrsa. will hold off on vancomycin for now given previous adverse reaction (consider linezolid if febrile or others signs of sepsis). - on linezolid (vancomycin allergy convincing), cefepime, ciprofloxacin (for uti) urinary tract infection patient with ciprofloxacin resistent urinary tract infection on [**2119-12-31**]. now on ceftriaxone day [**4-11**]. - continue ceftriaxone day [**4-11**] diabetes mellitus stable controlled on iss. inactive issues: anemia stable. hematocrit 28 on arrival from 36 on [**2119-12-30**]. now stable at 29. likely dilutional in the setting of fluid resuscitation post-arrest. also a report of mild gastrointesinal bleeding in the setting of lovenox administration. - maintain active type and screen - trend hematocrit - guaiac stools - transfusion goal > 25 in periarrest period right ear bleeding possible injury to tympanic membrane during resuscitation in context of anticoagulation. normal head ct at [**location (un) 1415**]. - otoscopy icu care: sedation: versed and fentanyl with propofol. fen: normal saline boluses for resuscitation parameters as above, replete electrolytes, has ngt for tube feeds. prophylaxis: subcutaneous heparin, ppi access: right ij placed, left radial arterial line communication: daughters [**name (ni) 755**] [**telephone/fax (1) 11255**], [**name2 (ni) 378**] [**telephone/fax (1) 11256**] code: full (discussed with patient) disposition: icu pending clinical improvement icu care nutrition: nutren pulmonary (full) - [**2120-1-3**] 05:49 pm 20 ml/hour glycemic control: lines: arterial line - [**2120-1-2**] 01:30 pm multi lumen - [**2120-1-2**] 03:00 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: full code disposition:",1
208,"title: chief complaint: 24 hour events: - patient alert/oriented and stated that she did not want a tracheostomy tube placed. family came in and daughter plans to bring in patient's glasses in the morning so that we can use a board to communicate. - ortho spine: no longer needs log roll precautions. okay to sit patient up. - hct: stable 27. - given hypernatremia increased free water flushes to 150cc q6hrs. - [**8-11**] this morning allergies: penicillins hives; sulfonamides unknown; bactrim (oral) (sulfamethoxazole/trimethoprim) rash; vancomycin rash; last dose of antibiotics: linezolid - [**2120-1-14**] 11:05 pm cefipime - [**2120-1-16**] 10:09 pm infusions: other icu medications: pantoprazole (protonix) - [**2120-1-16**] 08:00 pm heparin sodium (prophylaxis) - [**2120-1-16**] 10:09 pm furosemide (lasix) - [**2120-1-16**] 10:10 pm fentanyl - [**2120-1-17**] 04:01 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2120-1-17**] 06:44 am vital signs hemodynamic monitoring fluid balance 24 hours since [**22**] am tmax: 38.1 c (100.6 tcurrent: 37.2 c (98.9 hr: 110 (77 - 111) bpm bp: 113/66(82) {73/35(49) - 128/79(97)} mmhg rr: 21 (16 - 27) insp/min spo2: 96% heart rhythm: st (sinus tachycardia) wgt (current): 150 kg (admission): 152 kg height: 69 inch total in: 854 ml 67 ml po: tf: 117 ml ivf: 527 ml 67 ml blood products: total out: 2,675 ml 550 ml urine: 2,675 ml 550 ml ng: stool: drains: balance: -1,821 ml -483 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cpap/psv vt (spontaneous): 459 (288 - 459) ml ps : 8 cmh2o rr (spontaneous): 22 peep: 8 cmh2o fio2: 40% rsbi: 63 pip: 16 cmh2o spo2: 96% abg: 7.46/63/128/40/18 ve: 9 l/min pao2 / fio2: 320 physical examination general: intubated lungs: coarse breath sounds bilaterally, occasional wheezes cv: distant heart sounds, regular, s1 and s2, ii/vi sem at rusb, no rubs or gallops abdomen: obese, +bs, no rebound/tenderness/guarding gu: foley with clear yellow urine ext: warm, well perfused, 2+ edema bilaterally to knees. left arterial line in place. neurologic: responds to commands, moves upper extremity, does not move lower extremity labs / radiology 143 k/ul 9.0 g/dl 102 mg/dl 0.4 mg/dl 40 meq/l 4.1 meq/l 38 mg/dl 102 meq/l 147 meq/l 28.1 % 7.4 k/ul [image002.jpg] [**2120-1-15**] 03:04 am [**2120-1-15**] 03:17 am [**2120-1-15**] 10:30 am [**2120-1-15**] 04:14 pm [**2120-1-15**] 04:50 pm [**2120-1-15**] 05:13 pm [**2120-1-16**] 04:04 am [**2120-1-16**] 05:02 pm [**2120-1-17**] 03:37 am [**2120-1-17**] 03:44 am wbc 19.6 8.9 8.0 7.4 hct 29.6 28.7 27.1 27.0 28.1 plt 188 118 137 143 cr 0.4 0.3 0.5 0.4 0.4 tco2 43 43 44 46 glucose 112 120 120 98 102 other labs: pt / ptt / inr:12.5/28.8/1.1, ck / ckmb / troponin-t:96/21/0.04, alt / ast:46/24, alk phos / t bili:72/0.6, differential-neuts:83.6 %, lymph:9.2 %, mono:6.7 %, eos:0.4 %, fibrinogen:215 mg/dl, lactic acid:0.9 mmol/l, albumin:2.5 g/dl, ldh:331 iu/l, ca++:8.2 mg/dl, mg++:2.2 mg/dl, po4:3.1 mg/dl [**1-17**] cxr final read pending; appears to be no interval change per our read [**1-16**] cxr over penetration makes assessment difficult. et tube and ng tube noted as on examination on [**1-14**]. right ij sheath has been removed. there is a right-sided picc line in place with its tip at the junction of the innominate veins. no pneumothorax seen on this extremely limited radiograph. [**1-15**] stool final; negative for c. diff [**1-15**] blood culture pending [**1-14**] sputum prelim; coag + staph aureus, gram negative rods [**1-14**] catheter tip rij prelim; coag negative staph [**1-14**] urine final; yeast 10,000-100,000 [**1-14**] blood culture pending assessment and plan 76 yo f history of copd on home oxygen, moderate to severe aortic stenosis and dchf who presented to [**location (un) 1415**] on [**2119-12-30**] with progressive dyspnea on exertion and cough productive of clear sputum transferred here after pea arrest with evidence of unstable t11 fracture now pod #5 s/p fusion t6 to l4, laminectomy t12-l2. . # fever, leukocytosis. downtrending. white cell count continues to downtrend. patient with fever to 100.6 at 1600 yesterday; down since then. fever workup blood cultures have been negative since [**2120-1-14**]; sputum with coag+ staph aureus; ortho spine noted that they used a type of biofilm to close the wound that is known to cause low grade fever for up to one week. - follow up cultures - monitor fever curve - continue cefepime (14 days for pseudomonas, d/c on [**1-17**]) - consider restarting linezolid (patient with adverse reaction to vancomycin) - consider re-obtain cbc with diff tomorrow am looking for bands . # sob/hypercarbic respiratory failure/nosocomial pneumonia: improving. patient tolerated vent settings psv 8/peep 8 overnight. patient deferred on placement of traceostomy tube yesterday. - continue to wean vent and trial psv 5/peep 5 today - continue to discuss with patient and patient s family regarding tracheostomy - continue to follow daily am cxr - change hydrocortisone from 25mg iv q8 to prednisone 60mg po - continue cefepime (14 days for pseudomonas, d/c on [**1-17**]) - continue albuterol, ipratropium - continue lasix 40mg iv bid with goal negative one to two liters . # t6 to l4 fusion, t12-l2 laminectomy: pod#4 s/p operative intervention for unstable t11 fracture. wound currently with continued serosanguinous drainage. ortho spine has ok d to discontinue logroll precaution. - follow up ortho spine recs need to touch base regarding continued drainage - continue fentanyl/lidocaine patch - continue to wean fentanyl bolus prn - continue to discuss with patient and patient s family regarding peg, likely bedside with ip once afebrile . # pain control: likely post-op. also has history of left shoulder dislocation. pain controlled currently. - pain control with fentanyl iv bolus and fentanyl patch - continue lidocaine patch . # anemia: stable. - maintain active type and screen - obtain q12 hr hct - maintain transfusion goal > 25 in peri-arrest period . # left shoulder disclocation: stable. recent films with no dislocation. - continue lidocaine patch - continue to monitor for signs of pain/dislocation . # s/p pea arrest: escaped serious myocardial damage. will discuss with team regarding cad management as etiology of pea arrest likely [**2-6**] to hypercarbic respiratory failure. . # uti: resolved on latest cultures; covered by cefepime. . # dm: restart iss given post-op stress in addition to ongoing steroids. can discontinue and restart [**hospital1 **] fingerstick at later date. . # fen: replete electrolytes prn; restart tube-feeds npo after midnight for possible bedside procedure; ngt changed to dobhoff # prophylaxis: heparin sc; pneumoboots; ppi; daily bowel regimen # access: right power picc, left radial arterial line # communication: daughters [**name (ni) 755**] [**telephone/fax (1) 11255**], [**name2 (ni) 378**] [**telephone/fax (1) 11256**] # code: full (discussed with patient) # disposition: icu pending clinical improvement icu care nutrition: glycemic control: lines: arterial line - [**2120-1-12**] 12:33 am picc line - [**2120-1-14**] 02:00 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: full code disposition:",1
209,"alteration in nutrition assessment: pt w/ very poor po intake, refused po meds and sips of liquid. unable to swallow meds crushed in applesauce .overall very fragile and weak. pt has refused placement of ngt or dophoff . action: pt specific tpn up at 6pm response: no adverse reaction noted plan: team will need to order tpn if no transferred to rehab altered mental status (not delirium) assessment: ms waxes and wanes oriented x 1 oriented to self only overnight. speech continues to be very soft and garbled , difficult to understand. pt believed he was at home when asked where he was. unaware of season of year or the year. action: pt given morphine 1 mg at 2200 and 0500 for generalized back pain with activity. pt refusing all mouth care from me this evening, but has been cooperative with back care and turning. pt really having trouble getting thoughts out verbally and becomes frustrated. pt seems to be more agitated when hr in raf. response: . frequent reorientation. pt a bit quieter and calmer now- as compared to previous shift plan: cont to reorient, provide quiet/calm environment. pneumonia, other assessment: patient with unilateral multi-lobar pulmonary infiltrate. ls rhonchorous throughout. rr teens to 30s, weak/congested non-productive cough. received pt on 4l via n/c. very difficult to get a good o2 sat on pt. fluctuating between 87-96% on o2. sat s dropped to consistently low 80 s at 0500 and pt placed on 35% fio2 face tent. sat s increased within 10 minutes to 90-92% action: given flagyl and vanco. response: no change in respiratory status. cxr slightly improved. . pt able to be weaned off face tent. plan: cont w/ antibiotics, ? d/c to ltac facility. atrial fibrillation (afib) assessment: [**name (ni) **] pt has been in ventricular bijeminy, sinus arrhythmia and nsr with multi pvc s and pac s. pt poorly tolerates fast or abnormal rhythm. pt seems to desaturtate when in afib or sinus arrhythmia. at 0600 pt when into raf with hr 140-160. lopressor 10mg ivp given with little effect. hr decreased to 120 action: diltiazem 10mg ivp given in divided doses. continue on lopressor 7.5mg q6hr response: monitor plan: continue iv lopressor and stat doses of diltiazem",0
210,"alteration in nutrition assessment: pt w/ very poor po intake, refused po meds and sips of liquid. unable to swallow meds crushed in applesauce .overall very fragile and weak. pt has refused placement of ngt or dophoff . action: pt specific tpn up at 6pm response: no adverse reaction noted plan: team will need to order tpn if no transferred to rehab altered mental status (not delirium) assessment: ms waxes and wanes oriented x 1 oriented to self only overnight. speech continues to be very soft and garbled , difficult to understand. pt believed he was at home when asked where he was. unaware of season of year or the year. action: pt given morphine 1 mg at 2200 and 0500 for generalized back pain with activity. pt refusing all mouth care from me this evening, but has been cooperative with back care and turning. pt really having trouble getting thoughts out verbally and becomes frustrated. pt seems to be more agitated when hr in raf. response: . frequent reorientation. pt a bit quieter and calmer now- as compared to previous shift plan: cont to reorient, provide quiet/calm environment. pneumonia, other assessment: patient with unilateral multi-lobar pulmonary infiltrate. ls rhonchorous throughout. rr teens to 30s, weak/congested non-productive cough. received pt on 4l via n/c. very difficult to get a good o2 sat on pt. fluctuating between 87-96% on o2. sat s dropped to consistently low 80 s at 0500 and pt placed on 35% fio2 face tent. sat s increased within 10 minutes to 90-92% action: given flagyl and vanco. response: no change in respiratory status. cxr slightly improved. . pt able to be weaned off face tent. plan: cont w/ antibiotics, ? d/c to ltac facility. atrial fibrillation (afib) assessment: [**name (ni) **] pt has been in ventricular bijeminy, sinus arrhythmia and nsr with multi pvc s and pac s. pt poorly tolerates fast or abnormal rhythm. pt seems to desaturtate when in afib or sinus arrhythmia. at 0600 pt when into raf with hr 140-160. lopressor 10mg ivp given with little effect. hr decreased to 120 action: diltiazem 10mg ivp given in divided doses. continue on lopressor 7.5mg q6hr response: monitor plan: continue iv lopressor and stat doses of diltiazem ------ protected section ------ as of 0640 pt remains in a afutter with rate 90-100 ------ protected section addendum entered by:[**name (ni) 3990**] [**last name (namepattern1) 4178**], rn on:[**2204-1-12**] 06:47 ------",0
211,"chief complaint: pea arrest at [**location (un) 1415**] in context copd flare, successful ressusciation, no broken spine, bacteremia. 24 hour events: trans esophageal echo - at [**2120-1-3**] 10:22 am pan culture - at [**2120-1-3**] 08:24 pm temp 100.8. - spoke with family re: course of events and extent of injuries, family agreed that surgery is very high risk and should not be attempted at this time, but may be revisited at a later date - orthospine: willing to take patient to or if requested, but communicate the risk involved - echo: overall lv and rv sys. fxn likely normal, mod. as, no ai, 1+ mr, mod. pa htn - failed trial of psv now back on ac - spiked to 100.8 @ 20:00, blood + sputum + urine cx sent, started on cefepime + cipro + linezolid (note exfoliative rash with vanco) - blood cx gpc in clusters / sputum gnr - tube feeds started @ mn - shoulder contusions and pain on movement, palpation. allergies: penicillins hives; sulfonamides unknown; bactrim (oral) (sulfamethoxazole/trimethoprim) rash; vancomycin rash; last dose of antibiotics: levofloxacin - [**2120-1-2**] 09:59 pm piperacillin - [**2120-1-3**] 12:00 am ceftriaxone - [**2120-1-3**] 08:25 pm cefipime - [**2120-1-3**] 11:00 pm ciprofloxacin - [**2120-1-3**] 11:30 pm linezolid - [**2120-1-4**] 12:06 am infusions: fentanyl (concentrate) - 150 mcg/hour midazolam (versed) - 1 mg/hour other icu medications: heparin sodium (prophylaxis) - [**2120-1-3**] 02:26 pm pantoprazole (protonix) - [**2120-1-3**] 08:25 pm fentanyl - [**2120-1-4**] 07:00 am other medications: changes to medical and family history: no further. review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2120-1-4**] 07:49 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 38.2 c (100.8 tcurrent: 37.7 c (99.8 hr: 85 (69 - 104) bpm bp: 79/47(60) {79/43(60) - 130/59(85)} mmhg rr: 19 (11 - 26) insp/min spo2: 97% heart rhythm: sr (sinus rhythm) height: 69 inch cvp: 7 (7 - 12)mmhg co/ci (fick): (-3.1 l/min) / (-1.2 l/min/m2) mixed venous o2% sat: 76 - 180 total in: 1,407 ml 1,172 ml po: tf: 62 ml 154 ml ivf: 1,345 ml 1,019 ml blood products: total out: 1,065 ml 480 ml urine: 1,065 ml 480 ml ng: stool: drains: balance: 342 ml 692 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 400 (400 - 400) ml vt (spontaneous): 0 (0 - 615) ml ps : 20 cmh2o rr (set): 18 rr (spontaneous): 0 peep: 10 cmh2o fio2: 30% rsbi deferred: peep > 10 pip: 39 cmh2o plateau: 23 cmh2o compliance: 50 cmh2o/ml spo2: 97% abg: 7.31/65/77/32/3 ve: 7.8 l/min pao2 / fio2: 257 physical examination general appearance: overweight / obese eyes / conjunctiva: perrl, no(t) pupils dilated, no(t) conjunctiva pale, no(t) sclera edema head, ears, nose, throat: normocephalic, endotracheal tube, ng tube cardiovascular: (s1: normal), (s2: normal, distant), no(t) s3, no(t) s4, no(t) rub, (murmur: no(t) systolic, no(t) diastolic) peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) respiratory / chest: (expansion: symmetric), (breath sounds: clear : , wheezes : ) abdominal: soft, non-tender, bowel sounds present extremities: right lower extremity edema: trace, left lower extremity edema: trace, no(t) cyanosis, no(t) clubbing musculoskeletal: no(t) muscle wasting, unable to stand skin: not assessed, no(t) rash: , no(t) jaundice neurologic: responds to: not assessed, movement: not assessed, sedated, tone: not assessed labs / radiology 279 k/ul 9.0 g/dl 151 mg/dl 0.7 mg/dl 32 meq/l 4.6 meq/l 41 mg/dl 109 meq/l 144 meq/l 28.5 % 18.5 k/ul [image002.jpg] [**2120-1-2**] 02:32 pm [**2120-1-2**] 07:21 pm [**2120-1-2**] 10:00 pm [**2120-1-3**] 03:43 am [**2120-1-3**] 04:00 am [**2120-1-3**] 04:22 am [**2120-1-3**] 11:08 am [**2120-1-3**] 06:30 pm [**2120-1-4**] 04:16 am [**2120-1-4**] 04:48 am wbc 19.9 18.5 hct 30.1 29.7 28.5 plt 335 279 cr 0.7 0.7 tropt 0.04 0.04 tco2 33 32 33 33 34 glucose 110 124 122 151 other labs: pt / ptt / inr:13.1/30.8/1.1, ck / ckmb / troponin-t:825/21/0.04, alt / ast:31/46, alk phos / t bili:61/0.2, differential-neuts:83.0 %, lymph:12.7 %, mono:4.1 %, eos:0.1 %, lactic acid:0.9 mmol/l, ldh:215 iu/l, ca++:8.4 mg/dl, mg++:2.4 mg/dl, po4:2.6 mg/dl imaging: cxr pending/pending read. echo [**1-3**] the left atrium is elongated. left ventricular wall thicknesses are normal. 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 probably normal. right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve is not well seen. there is at least moderate aortic stenosis but doppler data are technically suboptimal for estimation of aortic valve area. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of [**2117-12-22**], the aortic valve gradient is now higher. microbiology: blood culture, routine (preliminary): gram positive coccus(cocci). in clusters. anaerobic bottle gram stain (final [**2120-1-3**]): gram positive cocci in clusters. reported by phone to [**first name4 (namepattern1) 11271**] [**last name (namepattern1) **] at 10:00pm on [**2120-1-3**]. mrsa screen (final [**2120-1-3**]): positive for methicillin resistant staph aureus. [**2120-1-2**] 1:16 pm sputum site: endotracheal source: endotracheal. gram stain (final [**2120-1-2**]): [**10-29**] pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): budding yeast. respiratory culture (preliminary): further incubation required to determine the presence or absence of commensal respiratory flora. gram negative rod(s). moderate growth. urine negative for legionella serogroup 1 antigen. sputum gram stain (final [**2120-1-3**]): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. ecg: none. assessment and plan hypotension (not shock) respiratory failure, acute (not ards/[**doctor last name **]) trauma, s/p this is a 76 year old female with a history of copd on home oxygen, moderate to severe aortic stenosis and diastolic heart failure who presented to [**location (un) 1415**] on [**2119-12-30**] with progressive dyspnea on exertion and cough productive of clear sputum transferred here after pea arrest with evidence of unstable t11 fracture. cord injury very likely, very poor surgical candidate, so will need to discuss this further with ortho, anesthetics and family. otherwise treat respiratory failure/copd. shortness of breath/hypercarbic respiratory failure patient with known copd at baseline on home oxygen. transition to psv, will wean fio2 for sat 90% and continue steroids / abx for component of copd flare / infection. cxr have been unremarkable but ct chest with multiple small nodules (seeding?) which could be infectious in origin. - continue cmv - continue solumedrol 80 mg iv q8h - continue albuterol and ipratropium autonomic lability and hypotension interesting unknown etiology. dm, cmv, pain (some not transmitted to forebrain/at spinal level/brainstem), spinal injury, sepsis, uti, pna, other contributors. - treat underlying causes, infection, pain. - fluid challenge now for resuscitation goals of cvp > 10, uop > 30 cc/hr, map > 60 - continue fentanyl and versed (instead of propofol) - check mixed venous oxygen saturation - phenylephrine for pressor as needed pea arrest enzymes now trending down. echo not remarkable. escaped serious myocardial damage. typical cad management. unstable t11 fracture family and ortho/anesthetics agreed yesterday to leave this for now, pending improved stability for surgery. leukocytosis contribution by pea arrest, uti, steroids, spinal fracture, but still need to be sensitive to history of mrsa bacteremia, now positive blood culture, possible pna and mrsa. will hold off on vancomycin for now given previous adverse reaction (consider linezolid if febrile or others signs of sepsis). - on linezolid (vancomycin allergy convincing), cefepime, ciprofloxacin (for uti) urinary tract infection patient with ciprofloxacin resistent urinary tract infection on [**2119-12-31**]. now on ceftriaxone day [**4-11**]. - continue ceftriaxone day [**4-11**] diabetes mellitus stable controlled on iss. inactive issues: anemia stable. hematocrit 28 on arrival from 36 on [**2119-12-30**]. now stable at 29. likely dilutional in the setting of fluid resuscitation post-arrest. also a report of mild gastrointesinal bleeding in the setting of lovenox administration. - maintain active type and screen - trend hematocrit - guaiac stools - transfusion goal > 25 in periarrest period right ear bleeding possible injury to tympanic membrane during resuscitation in context of anticoagulation. normal head ct at [**location (un) 1415**]. - otoscopy icu care: sedation: versed and fentanyl with propofol. fen: normal saline boluses for resuscitation parameters as above, replete electrolytes, has ngt for tube feeds. prophylaxis: subcutaneous heparin, ppi access: right ij placed, left radial arterial line communication: daughters [**name (ni) 755**] [**telephone/fax (1) 11255**], [**name2 (ni) 378**] [**telephone/fax (1) 11256**] code: full (discussed with patient) disposition: icu pending clinical improvement icu care nutrition: nutren pulmonary (full) - [**2120-1-3**] 05:49 pm 20 ml/hour glycemic control: lines: arterial line - [**2120-1-2**] 01:30 pm multi lumen - [**2120-1-2**] 03:00 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: full code disposition:",1
212,"title: physician resident progress note chief complaint: 24 hour events: -3 a.m.: had luq pain. received morphine 0.5 mg po -5:30 a.m., went into afib with normal hr and bp and no other ekg changes allergies: atorvastatin muscle/bone pai tylenol (oral) (dm hb/pseudoephed/acetamin/cp) muscle pain; ibuprofen muscle/bone pai rosuvastatin abdominal pain; last dose of antibiotics: infusions: furosemide (lasix) - 10 mg/hour other icu medications: furosemide (lasix) - [**2165-5-5**] 11:15 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2165-5-6**] 06:48 am vital signs hemodynamic monitoring fluid balance 24 hours since [**67**] am tmax: 36.4 c (97.5 tcurrent: 36.1 c (97 hr: 85 (63 - 85) bpm bp: 112/94(98) {112/47(65) - 138/94(98)} mmhg rr: 20 (14 - 27) insp/min spo2: 94% heart rhythm: af (atrial fibrillation) total in: 248 ml 128 ml po: 60 ml tf: ivf: 8 ml 68 ml blood products: total out: 965 ml 590 ml urine: 90 ml 590 ml ng: stool: drains: balance: -718 ml -462 ml respiratory support o2 delivery device: nasal cannula spo2: 94% abg: ///29/ physical examination general: elderly woman who is slow to respond to questions. complaining of abdominal pain. neck: supple. prominent carotid pulsations and external jugular vein but i am unable to locate her jvp reliably. cardiac: regular rhythm with normal s1 and s2. no murmurs rubs or gallops appreciated. lungs: +kyphosis. labored respirations with coarse crackles [**2-9**] of the way of her lung fields b/l. no significant wheeze. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. extremities: no lower extremity edema. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: distal pulses are dopplerable b/l. labs / radiology 239 k/ul 8.9 g/dl 137 mg/dl 4.4 mg/dl 29 meq/l 3.8 meq/l 108 mg/dl 75 meq/l 123 meq/l 25.7 % 7.4 k/ul [image002.jpg] [**2165-5-6**] 12:48 am wbc 7.4 hct 25.7 plt 239 cr 4.4 tropt 0.20 glucose 137 other labs: pt / ptt / inr:13.1/26.5/1.1, ck / ckmb / troponin-t:17//0.20, ca++:9.2 mg/dl, mg++:3.6 mg/dl, po4:5.8 mg/dl assessment and plan [**age over 90 52**]yo woman with h/o cad s/p pci, systolic chf with ef of 40%, and chronic kidney disease who is transferred to the ccu with respiratory distress. . # respiratory distress: the working diagnosis has been that the patient has pulmonary edema due to acute on chronic systolic heart failure. however, it is also possible that the patient actually has a pneumonia explaining her worsened respiratory status, possibly in the setting of aspiration (although no specific aspiration event was observed). for now, we will continue to treat for pulmonary edema. - confirmed that patient is okay to intubate if necessary - continue lasix gtt - will discuss possibility of renal stent vs hemodialysis with drs. [**last name (stitle) 11806**], [**name5 (ptitle) 2759**], and [**doctor last name **] - albuterol and ipratropium nebs . # altered mental status: most likely related to patient s hyponatremia. differential diagnosis includes infection, uremia, meds. - treat hyponatremia as below - minimize sedating meds . # hyponatremia: unclear if this is hypervolemic hypernatremia in setting of chf or siadh in the setting of a pulmonary process. urine lytes and osms may help to clarify this issue, although urine osm may be difficult to interpret in the setting of ongoing diuresis with furosemide. - diurese as above - f/u urine lytes . # abdominal pain: etiology unclear. bowel sounds present. - f/u on radiology read of kub - ensure adequate bowel regimen . # acute on chronic kidney injury chronic kidney disease: baseline cr 2.4-2.8 recently, current 4.3. the patient has atrophic right kidney and left renal artery stenosis. there has been discussion of possible stent of renal artery on [**5-6**]. patient s recent decline in kidney function is likely related to poor renal perfusion. atn is also possible. - check urine lytes - monitor for signs and symptoms of uremia - n-acetylcysteine in anticipation of possible dye load - will discuss options (renal artery stenting, hemodialysis, or comfort-directed care) with patient's providers as discussed above . # cad s/p bms to lcx [**2165**]: no evidence of active ischemia - continue asa 162 and plavix - continue carvedilol . # anemia: baseline hct 28-30, current hct 25.7: hct has been slowly trending down during course of her admission. underlying cause of her anemia is likely her renal failure, but unclear why her hct should be trending down. - recheck hct - maintain active type and screen - if continues to fall, will check hemolysis labs . # neck and back pain: although she has atherosclerotic disease, she is not hypertensive and does not have a widened mediastinum. her exam is consistent with musculoskeletal causes of pain. - note that she has adverse reaction (increased pain) to tylenol and ibuprofen - warm packs prn - lidocaine patch # hypertension: - continue felodipine per home regimen - will continue carvedilol (note that dose has been doubled from home dose of 12.5mg [**hospital1 **]) - holding hydralazine - would aim for sbps 120s-130s - continue isosorbide # hyperlipidemia: has not tolerated many statins # type 2 diabetes: diet-controlled. - insulin sliding scale (gentle) # gerd: continue famotidine 20 mg tablet per outpatient regimen icu care nutrition: diabetic, low salt diet; npo p mn for possible stent glycemic control: lines: 20 gauge - [**2165-5-5**] 10:30 pm 22 gauge - [**2165-5-5**] 10:35 pm prophylaxis: dvt: subq heparin stress ulcer: vap: comments: communication: comments: daughter [**name (ni) 3112**] is hcp: [**telephone/fax (1) 11993**] code status: dnr but okay to intubate disposition: ccu",1
213,"title: physician resident progress note chief complaint: 24 hour events: -3 a.m.: had luq pain. received morphine 0.5 mg po -5:30 a.m., went into afib with normal hr and bp and no other ekg changes allergies: atorvastatin muscle/bone pai tylenol (oral) (dm hb/pseudoephed/acetamin/cp) muscle pain; ibuprofen muscle/bone pai rosuvastatin abdominal pain; last dose of antibiotics: infusions: furosemide (lasix) - 10 mg/hour other icu medications: furosemide (lasix) - [**2165-5-5**] 11:15 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2165-5-6**] 06:48 am vital signs hemodynamic monitoring fluid balance 24 hours since [**67**] am tmax: 36.4 c (97.5 tcurrent: 36.1 c (97 hr: 85 (63 - 85) bpm bp: 112/94(98) {112/47(65) - 138/94(98)} mmhg rr: 20 (14 - 27) insp/min spo2: 94% heart rhythm: af (atrial fibrillation) total in: 248 ml 128 ml po: 60 ml tf: ivf: 8 ml 68 ml blood products: total out: 965 ml 590 ml urine: 90 ml 590 ml ng: stool: drains: balance: -718 ml -462 ml respiratory support o2 delivery device: nasal cannula spo2: 94% abg: ///29/ physical examination general: elderly woman who is slow to respond to questions. complaining of abdominal pain. neck: supple. prominent carotid pulsations and external jugular vein but i am unable to locate her jvp reliably. cardiac: regular rhythm with normal s1 and s2. no murmurs rubs or gallops appreciated. lungs: +kyphosis. decreased breath sounds at bilateral lung bases r>l. abdomen: exam inconsistent. difficult to get patient to relax abdominal muscles. intermittently complains of/denies abdominal pain/tenderness. extremities: no lower extremity edema. labs / radiology 239 k/ul 8.9 g/dl 137 mg/dl 4.4 mg/dl 29 meq/l 3.8 meq/l 108 mg/dl 75 meq/l 123 meq/l 25.7 % 7.4 k/ul [image002.jpg] [**2165-5-6**] 12:48 am wbc 7.4 hct 25.7 plt 239 cr 4.4 tropt 0.20 glucose 137 other labs: pt / ptt / inr:13.1/26.5/1.1, ck / ckmb / troponin-t:17//0.20, ca++:9.2 mg/dl, mg++:3.6 mg/dl, po4:5.8 mg/dl assessment and plan [**age over 90 52**]yo woman with h/o cad s/p pci, systolic chf with ef of 40%, and chronic kidney disease who is transferred to the ccu with respiratory distress. . # respiratory distress: the working diagnosis has been that the patient has pulmonary edema due to acute on chronic systolic heart failure. however, it is also possible that the patient actually has a pneumonia explaining her worsened respiratory status, possibly in the setting of aspiration (although no specific aspiration event was observed). for now, we will continue to treat for pulmonary edema. - confirmed that patient is okay to intubate if necessary - continue lasix gtt - will discuss possibility of renal stent vs hemodialysis with drs. [**last name (stitle) 11806**], [**name5 (ptitle) 2759**], and [**doctor last name **] - albuterol and ipratropium nebs . # altered mental status: most likely related to patient s hyponatremia. differential diagnosis includes infection, uremia, meds. - treat hyponatremia as below - minimize sedating meds . # hyponatremia: unclear if this is hypervolemic hypernatremia in setting of chf or siadh in the setting of a pulmonary process. urine lytes and osms may help to clarify this issue, although urine osm may be difficult to interpret in the setting of ongoing diuresis with furosemide. - diurese as above - f/u urine lytes . # abdominal pain: etiology unclear. bowel sounds present. - f/u on radiology read of kub - ensure adequate bowel regimen . # acute on chronic kidney injury chronic kidney disease: baseline cr 2.4-2.8 recently, current 4.3. the patient has atrophic right kidney and left renal artery stenosis. there has been discussion of possible stent of renal artery on [**5-6**]. patient s recent decline in kidney function is likely related to poor renal perfusion. atn is also possible. - check urine lytes - monitor for signs and symptoms of uremia - n-acetylcysteine in anticipation of possible dye load - will discuss options (renal artery stenting, hemodialysis, or comfort-directed care) with patient's providers as discussed above . # cad s/p bms to lcx [**2165**]: no evidence of active ischemia - continue asa 162 and plavix - continue carvedilol . # anemia: baseline hct 28-30, current hct 25.7: hct has been slowly trending down during course of her admission. underlying cause of her anemia is likely her renal failure, but unclear why her hct should be trending down. - recheck hct - maintain active type and screen - if continues to fall, will check hemolysis labs . # neck and back pain: although she has atherosclerotic disease, she is not hypertensive and does not have a widened mediastinum. her exam is consistent with musculoskeletal causes of pain. - note that she has adverse reaction (increased pain) to tylenol and ibuprofen - warm packs prn - lidocaine patch # hypertension: - continue felodipine per home regimen - will continue carvedilol (note that dose has been doubled from home dose of 12.5mg [**hospital1 **]) - holding hydralazine - would aim for sbps 120s-130s - continue isosorbide # hyperlipidemia: has not tolerated many statins # type 2 diabetes: diet-controlled. - insulin sliding scale (gentle) # gerd: continue famotidine 20 mg tablet per outpatient regimen icu care nutrition: diabetic, low salt diet; npo p mn for possible stent glycemic control: lines: 20 gauge - [**2165-5-5**] 10:30 pm 22 gauge - [**2165-5-5**] 10:35 pm prophylaxis: dvt: subq heparin stress ulcer: vap: comments: communication: comments: daughter [**name (ni) 3112**] is hcp: [**telephone/fax (1) 11993**] code status: dnr but okay to intubate disposition: ccu",1
214,"title: physician resident progress note chief complaint: 24 hour events: -3 a.m.: had luq pain. received morphine 0.5 mg po -5:30 a.m., went into afib with normal hr and bp and no other ekg changes allergies: atorvastatin muscle/bone pai tylenol (oral) (dm hb/pseudoephed/acetamin/cp) muscle pain; ibuprofen muscle/bone pai rosuvastatin abdominal pain; last dose of antibiotics: infusions: furosemide (lasix) - 10 mg/hour other icu medications: furosemide (lasix) - [**2165-5-5**] 11:15 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2165-5-6**] 06:48 am vital signs hemodynamic monitoring fluid balance 24 hours since [**67**] am tmax: 36.4 c (97.5 tcurrent: 36.1 c (97 hr: 85 (63 - 85) bpm bp: 112/94(98) {112/47(65) - 138/94(98)} mmhg rr: 20 (14 - 27) insp/min spo2: 94% heart rhythm: af (atrial fibrillation) total in: 248 ml 128 ml po: 60 ml tf: ivf: 8 ml 68 ml blood products: total out: 965 ml 590 ml urine: 90 ml 590 ml ng: stool: drains: balance: -718 ml -462 ml respiratory support o2 delivery device: nasal cannula spo2: 94% abg: ///29/ physical examination general: elderly woman who is mildly tachypneic but using accessory muscles to breath and exhales against pursed lips. keeps eyes closed but will open them to respond to questions; easily roused. answers that she is ""in [**location (un) **]"" but then corrects that she ""wishes to be in [**location (un) **]."" can give first names of her grandparents and interacts w/ her family appropriately. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple. prominent carotid pulsations and external jugular vein but i am unable to locate her jvp reliably. neck and upper back are sore and feel better when rubbed. cardiac: pmi is not displaced. regular rhythm with normal s1 and s2. no murmurs rubs or gallops appreciated. lungs: +kyphosis. labored respirations with coarse crackles [**2-9**] of the way of her lung fields b/l. no significant wheeze. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. extremities: no lower extremity edema. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: distal pulses are dopplerable b/l. labs / radiology 239 k/ul 8.9 g/dl 137 mg/dl 4.4 mg/dl 29 meq/l 3.8 meq/l 108 mg/dl 75 meq/l 123 meq/l 25.7 % 7.4 k/ul [image002.jpg] [**2165-5-6**] 12:48 am wbc 7.4 hct 25.7 plt 239 cr 4.4 tropt 0.20 glucose 137 other labs: pt / ptt / inr:13.1/26.5/1.1, ck / ckmb / troponin-t:17//0.20, ca++:9.2 mg/dl, mg++:3.6 mg/dl, po4:5.8 mg/dl assessment and plan [**age over 90 52**]yo woman with h/o cad s/p pci, systolic chf with ef of 40%, and chronic kidney disease who is transferred to the ccu with respiratory distress. # respiratory distress: ms. [**known lastname 11794**] likely has pulmonary edema due to acute on chronic systolic heart failure. it is odd that her initial cxr did not show evidence of vascular congestion and that subsequent cxrs in the hospital have actually worsened despite increasing doses of diuresis (though perhaps she has not really diuresed in response to this lasix). moreover, she has not had documented acute hypertension prior to her episodes of ""flashing."" other possible causes of her worsening tachypnea and hypoxia include aspiration pneumonitis or undiagnosed copd. she has been in the company of her daughter almost all day and no aspiration events have been witnessed. also, she likely has some age-related emphysematous changes but does not have a strong enough smoking history to suggest copd. finally, it is intriguing that she has an asd, though i cannot explain how diuresis might cause the shunt to go from right to left and i would expect her to be more markedly hypoxic were that the mechanism of her respiratory distress. - confirmed that patient is okay to intubate if necessary - lasix 120mg iv now followed by lasix gtt - will discuss possibility of renal stent vs hemodialysis with drs. [**last name (stitle) 11806**], [**name5 (ptitle) 2759**], and [**doctor last name **] in the morning - would add metolazone to assist with diuresis if necessary - continue hydralazine and isosorbide - atrovent nebs # cad s/p bms to lcx [**2165**]: - continue asa 162 and plavix - continue carvedilol - no evidence of acute ischemia on ekg - will cycle cardiac biomarkers given chest pain # chronic kidney disease: baseline cr 2.4-2.8 recently, current 4.3: note that patient has atrophic right kidney and left renal artery stenosis. there has been discussion of possible stent of renal artery on [**5-6**]. - n-acetylcysteine in anticipation of possible dye load - will discuss options (renal artery stenting, hemodialysis, or comfort-directed care) with patient's providers as discussed above # anemia: baseline hct 28-30, current hct 23.8: hct has been slowly trending down during course of her admission. underlying cause of her anemia is likely her renal failure, but unclear why she might be acutely worse. - recheck hct - maintain active type and screen - if continues to fall, will check hemolysis labs # [**last name (un) **] and back pain: although she has atherosclerotic disease, she is not hypertensive and does not have a widened mediastinum. her exam is consistent with musculoskeletal causes of pain. - note that she has adverse reaction (increased pain) to tylenol and ibuprofen - warm packs prn # hypertension: - continue felodipine per home regimen - will continue carvedilol (note that dose has been doubled from home dose of 12.5mg [**hospital1 **]) - will continue hydralazine (also increased from home dose) - would aim for sbps 120s-130s - isosorbide as above # hyperlipidemia: has not tolerated many statins # type 2 diabetes: diet-controlled. - insulin sliding scale (gentle) # gerd: - continue famotidine 20 mg tablet per outpatient regimen icu care nutrition: diabetic, low salt diet; npo p mn for possible stent glycemic control: lines: 20 gauge - [**2165-5-5**] 10:30 pm 22 gauge - [**2165-5-5**] 10:35 pm prophylaxis: dvt: subq heparin stress ulcer: vap: comments: communication: comments: daughter [**name (ni) 3112**] is hcp: [**telephone/fax (1) 11993**] code status: dnr but okay to intubate disposition: ccu",1
215,"title: physician resident progress note chief complaint: 24 hour events: -3 a.m.: had luq pain. received morphine 0.5 mg po -5:30 a.m., went into afib with normal hr and bp and no other ekg changes allergies: atorvastatin muscle/bone pai tylenol (oral) (dm hb/pseudoephed/acetamin/cp) muscle pain; ibuprofen muscle/bone pai rosuvastatin abdominal pain; last dose of antibiotics: infusions: furosemide (lasix) - 10 mg/hour other icu medications: furosemide (lasix) - [**2165-5-5**] 11:15 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2165-5-6**] 06:48 am vital signs hemodynamic monitoring fluid balance 24 hours since [**67**] am tmax: 36.4 c (97.5 tcurrent: 36.1 c (97 hr: 85 (63 - 85) bpm bp: 112/94(98) {112/47(65) - 138/94(98)} mmhg rr: 20 (14 - 27) insp/min spo2: 94% heart rhythm: af (atrial fibrillation) total in: 248 ml 128 ml po: 60 ml tf: ivf: 8 ml 68 ml blood products: total out: 965 ml 590 ml urine: 90 ml 590 ml ng: stool: drains: balance: -718 ml -462 ml respiratory support o2 delivery device: nasal cannula spo2: 94% abg: ///29/ physical examination general: elderly woman who is slow to respond to questions. complaining of abdominal pain. neck: supple. prominent carotid pulsations and external jugular vein but i am unable to locate her jvp reliably. cardiac: regular rhythm with normal s1 and s2. no murmurs rubs or gallops appreciated. lungs: +kyphosis. decreased breath sounds at bilateral lung bases r>l. abdomen: exam inconsistent. difficult to get patient to relax abdominal muscles. intermittently complains of/denies abdominal pain/tenderness. extremities: no lower extremity edema. labs / radiology 239 k/ul 8.9 g/dl 137 mg/dl 4.4 mg/dl 29 meq/l 3.8 meq/l 108 mg/dl 75 meq/l 123 meq/l 25.7 % 7.4 k/ul [image002.jpg] [**2165-5-6**] 12:48 am wbc 7.4 hct 25.7 plt 239 cr 4.4 tropt 0.20 glucose 137 other labs: pt / ptt / inr:13.1/26.5/1.1, ck / ckmb / troponin-t:17//0.20, ca++:9.2 mg/dl, mg++:3.6 mg/dl, po4:5.8 mg/dl assessment and plan [**age over 90 52**]yo woman with h/o cad s/p pci, systolic chf with ef of 40%, and chronic kidney disease who is transferred to the ccu with respiratory distress. . # respiratory distress: the working diagnosis has been that the patient has pulmonary edema due to acute on chronic systolic heart failure. however, it is also possible that the patient actually has a pneumonia explaining her worsened respiratory status, possibly in the setting of aspiration (although no specific aspiration event was observed). for now, we will continue to treat for pulmonary edema. - confirmed that patient is okay to intubate if necessary - continue lasix gtt - will discuss possibility of renal stent vs hemodialysis with drs. [**last name (stitle) 11806**], [**name5 (ptitle) 2759**], and [**doctor last name **] - albuterol and ipratropium nebs . # altered mental status: most likely related to patient s hyponatremia. differential diagnosis includes infection, uremia, meds. - treat hyponatremia as below - minimize sedating meds . # hyponatremia: unclear if this is hypervolemic hypernatremia in setting of chf or siadh in the setting of a pulmonary process. urine lytes and osms may help to clarify this issue, although urine osm may be difficult to interpret in the setting of ongoing diuresis with furosemide. - diurese as above - f/u urine lytes . # abdominal pain: etiology unclear. bowel sounds present. - f/u on radiology read of kub - ensure adequate bowel regimen . # acute on chronic kidney injury chronic kidney disease: baseline cr 2.4-2.8 recently, current 4.3. the patient has atrophic right kidney and left renal artery stenosis. there has been discussion of possible stent of renal artery on [**5-6**]. patient s recent decline in kidney function is likely related to poor renal perfusion. atn is also possible. - check urine lytes - monitor for signs and symptoms of uremia - n-acetylcysteine in anticipation of possible dye load - will discuss options (renal artery stenting, hemodialysis, or comfort-directed care) with patient's providers as discussed above . # cad s/p bms to lcx [**2165**]: no evidence of active ischemia - continue asa 162 and plavix - continue carvedilol . # anemia: baseline hct 28-30, current hct 25.7: hct has been slowly trending down during course of her admission. underlying cause of her anemia is likely her renal failure, but unclear why her hct should be trending down. - recheck hct - maintain active type and screen - if continues to fall, will check hemolysis labs . # neck and back pain: although she has atherosclerotic disease, she is not hypertensive and does not have a widened mediastinum. her exam is consistent with musculoskeletal causes of pain. - note that she has adverse reaction (increased pain) to tylenol and ibuprofen - warm packs prn - lidocaine patch # hypertension: - continue felodipine per home regimen - will continue carvedilol (note that dose has been doubled from home dose of 12.5mg [**hospital1 **]) - holding hydralazine - would aim for sbps 120s-130s - continue isosorbide # hyperlipidemia: has not tolerated many statins # type 2 diabetes: diet-controlled. - insulin sliding scale (gentle) # gerd: continue famotidine 20 mg tablet per outpatient regimen icu care nutrition: diabetic, low salt diet; npo p mn for possible stent glycemic control: lines: 20 gauge - [**2165-5-5**] 10:30 pm 22 gauge - [**2165-5-5**] 10:35 pm prophylaxis: dvt: subq heparin stress ulcer: vap: comments: communication: comments: daughter [**name (ni) 3112**] is hcp: [**telephone/fax (1) 11993**] code status: dnr but okay to intubate disposition: ccu ------ protected section ------ title: ccu attending progress note cardiology teaching physician note on this day i saw, examined and was physically present with the resident / fellow for the key portions of the services provided. i agree with the above note and plans. i have also reviewed the notes of dr. [**last name (stitle) 5186**]. i would add the following remarks: history creatinine has increased substantially, potentially due to over diuresis with superimposed pneumonia. medical decision making would recommend maintain euvolemia or slightly positive to see if renal function improves. family is aware of her condition. total time spent on patient care: 30 minutes of critical care time ------ protected section addendum entered by:[**name (ni) 5899**] [**last name (namepattern1) 8906**], md on:[**2165-5-6**] 20:54 ------",1
216,"renal failure, end stage (end stage renal disease, esrd) assessment: no usable hd access at this time. infected a-v fistula in left arm +bruit, +thrill. lungs clear bilaterally, received pt on 2l o2 nasal prongs. late pm pt complained of slight difficulty breathing, saturating well and lungs still cta. anuric. ate well at dinner, diet and fluids tolerated well. action: us cancelled and instead, ct of torso done. pt premedicated with motrin and benadryl, then ampicillin desensitization regimen given over 3.5 hours. iv fluids initially infused @ 75cch, then reduced to kvo when pt c/o slight difficulty breathing. o2 increased to 4l n/prongs when pt asleep and sats 92%. morphine 1mg iv x1 for generalized discomfort. response: bp normotensive overnoc. good effect from abx premedication, tolerated ampicilling without adverse reaction. settled and slept well after morphine, no further complaints of discomfort. plan: micu plans to consult transplant service to follow avf place temporary hd cath with vip port if avf determined to be infected",0
217,"renal failure, end stage (end stage renal disease, esrd) assessment: no usable hd access at this time. infected a-v fistula in left arm +bruit, +thrill. lungs clear bilaterally, received pt on 2l o2 nasal prongs. late pm pt complained of slight difficulty breathing, saturating well and lungs still cta. anuric. ate well at dinner, diet and fluids tolerated well. action: us cancelled and instead, ct of torso done. pt premedicated with motrin and benadryl, then ampicillin desensitization regimen given over 3.5 hours. iv fluids initially infused @ 75cch, then reduced to kvo when pt c/o slight difficulty breathing. o2 increased to 4l n/prongs when pt asleep and sats 92%. morphine 1mg iv x1 for generalized discomfort. response: bp normotensive overnoc. good effect from abx premedication, tolerated ampicilling without adverse reaction. settled and slept well after morphine, no further complaints of discomfort. hct stable @ 29 this am. plan: micu plans to consult transplant service to follow avf. place temporary hd cath with vip port if avf determined to be infected. ------ protected section ------ at 0640, pt called c/o shortness of breath, o2 sats in low 90 tachycardic 110, breath sounds markedly diminished. micu team alerted and epipen administered into rt arm with immediate relief. pt is now coughing up blood, micu team present and aware. patient states that episode felt like asthma takes mdi s at home. morphine 1mg given ivp for generalized discomfort at this time. cxr pending. ------ protected section addendum entered by:[**name (ni) 11597**] [**name8 (md) 11598**], rn on:[**2165-3-2**] 06:51 ------",0
218,"renal failure, end stage (end stage renal disease, esrd) assessment: no usable hd access at this time. infected a-v fistula in left arm +bruit, +thrill. lungs clear bilaterally, received pt on 2l o2 nasal prongs. late pm pt complained of slight difficulty breathing, saturating well and lungs still cta. anuric. ate well at dinner, diet and fluids tolerated well. action: us cancelled and instead, ct of torso done. pt premedicated with motrin and benadryl, then ampicillin desensitization regimen given over 3.5 hours. iv fluids initially infused @ 75cch, then reduced to kvo when pt c/o slight difficulty breathing. o2 increased to 4l n/prongs when pt asleep and sats 92%. morphine 1mg iv x1 for generalized discomfort. response: bp normotensive overnoc. good effect from abx premedication, tolerated ampicilling without adverse reaction. settled and slept well after morphine, no further complaints of discomfort. hct stable @ 29 this am. plan: micu plans to consult transplant service to follow avf. place temporary hd cath with vip port if avf determined to be infected.",0
219,"chief complaint: 24 hour events: - weaning off oxygen from face tent down to nasal cannula - no events allergies: clindamycin unknown; last dose of antibiotics: cefipime - [**2104-5-19**] 10:07 pm metronidazole - [**2104-5-19**] 10:40 pm infusions: other icu medications: other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2104-5-20**] 05:50 am vital signs hemodynamic monitoring fluid balance 24 hours since [**06**] am tmax: 37.3 c (99.2 tcurrent: 35.8 c (96.5 hr: 67 (65 - 92) bpm bp: 129/55(74) {102/41(57) - 175/75(83)} mmhg rr: 22 (15 - 29) insp/min spo2: 97% heart rhythm: sr (sinus rhythm) total in: 153 ml po: tf: ivf: 153 ml blood products: total out: 2,000 ml 0 ml urine: ng: stool: drains: balance: -1,847 ml 0 ml respiratory support o2 delivery device: nasal cannula, aerosol-cool ventilator mode: cpap/psv vt (spontaneous): 577 (476 - 577) ml ps : 5 cmh2o rr (spontaneous): 28 peep: 5 cmh2o fio2: 40% pip: 8 cmh2o spo2: 97% abg: ///28/ ve: 12.9 l/min physical examination general: lying in bed at 10 degrees, nad, speaking in complete sentences heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: unlabored respirations, decreased breath sounds bases, crackles bibasilarly, no wheezes/rhonchi cv: s1, s2 regular rhythm, normal rate abdomen: soft, ntnd, no gaurding gu: no foley ext: no edema, lue fistula erythema, warmth, no obvious fluctuance, + palpable thrill labs / radiology 223 k/ul 12.2 g/dl 130 mg/dl 5.8 mg/dl 28 meq/l 5.1 meq/l 32 mg/dl 96 meq/l 139 meq/l 40.0 % 10.1 k/ul [image002.jpg] [**2104-5-20**] 03:29 am wbc 10.1 hct 40.0 plt 223 cr 5.8 tropt 0.10 glucose 130 ck / ckmb / troponin-t:28//0.10, differential-neuts:88.7 %, lymph:8.6 %, mono:1.9 %, eos:0.2 %, lactic acid:0.9 mmol/l, ca++:9.1 mg/dl, mg++:1.9 mg/dl, po4:5.0 mg/dl micro: [**2104-5-19**]: - gram positive cocci in clusters 2/2 bottles assessment and plan assessment: [**age over 90 382**]m with history of alzheimer's dementia, hypertension, esrd on hd (m/w/f), history of aspiration pneumonia with hypoxemia and fever at hemodialysis found to have gram positive cocci bacteremia. . plan: . # gram positive cocci bacteremia: the most likely site of infection is the cellulitis overlying av fistula site given erythema, warmth on exam and recent instrumentation. question whether av fistula site infection although no obvious fluctuance on exam. pneumonia also considered given hypoxemia although chest film more consistent with pulmonary edema than infection. - f/u speciation and sensitivity - daily blood cultures - tte to evaluate for vegetations - continue vancomycin for now pending speciation - low threshold to change to daptomycin given history of vre - thoracic surgery consult - discuss hd access with renal - consider id consult - elevate the arm . #hypoxemia: the differential diagnosis includes pulmonary edema/volume overload, aspiration pneumonia, bronchospasm, pneumothorax. there is likely significant contribution from pulmonary edema in the setting missing hemodialysis and uncontrolled hypertension in setting of diastolic heart failure. pneumonia, in particular aspiration pneumonia, is considered given patient history, fever, and leukocytosis although no clear evidence of infiltrate on imaging. pneumothorax is unlikely given evidence of lung shadowing in right apical field on imaging. given rash following administration of clindamycin, bronchospasm and upper airway edema are considered although no evidence of wheezing or stridor on exam. cardiac enzymes negative. reduced oxygen requirement overnight s/p removal of 2l of fluid at hd, currently sating in high 90s on nc- - treat for hap with vanco, cefipime (id approval in am); pt should receive additional 1 gm vancomycin - flagyl to cover aspiration - sputum culture, legionella culture (does not make urine) - wean oxygen as tolerated after volume removal of 2l as per renal - f/u thoracic surgery recommendations - mechanical soft diet given aspiration risk . # esrd: - renal recs - hd m/w/f schedule - discuss utility of access site given concern for infection with renal/transplant surgery - continue calcium acetate tid with meals - f/u transplant surgery recommendations . #fever: differential includes cellulitis/av fistula infection, pulmonary infection. most likely source of infection is av fistula site given physical exam. pneumonia considered given hypoxemia although cxr more c/w pulmonary edema with interval improvement following hd. c. difficile associated disease considered although no history of diarrhea. - blood cultures - sputum cultures - vanco/cefepime/flagyl for now - check stool c. diff . #hyperkalemia: likely due to end stage renal disease in setting of missing hemodialysis session today. no ekg changes. normalized s/p hemodialysis. . #hypertension: most likely secondary to volume overload in the setting of not taking home antihypertensives medications today. no evidence of end organ ischemia clinically or by labs. patient weaned off nitro gtt overnight, currently normotensive on home medications. - start amlodipine, midodrine, metoprolol, and lisinopril .. # acute on chronic diastolic chf: most recent tte was in [**2102**] showing normal systolic function (ef>55%) but moderate diastolic dysfunction. patient with volume overload clinically and by labs with elevated bnp and on imaging with pulmonary edema. likely exacerbated by volume overload in the setting of missing hemodialysis and uncontrolled htn. - continue metoprolol, ccb, and lisinopril . # allergic reaction? patient currently has no rash, no evidence of bronchospasm or upper airway edema. given dose of steroids in ed. - list clindamycin as adverse reaction - no indication to continue steroids at this time . #mental status: patient is aox0 at baseline with poor short-term memory and known alzheimer's dementia. currently appears at baseline. - haldol prn agitation - anticipate some delerium with infection. . # cad? on aspirin. unclear if [**age over 90 52**] y/o dm m warrants asa for primary prevention. . # fen: replete electrolytes, mechanical soft diet # prophylaxis: subcutaneous heparin # access: peripherals # communication: daughter [**name (ni) **] ([**telephone/fax (1) 12197**]) # code: dnr/dni # disposition: icu pending clinical improvement icu care nutrition: glycemic control: lines: 18 gauge - [**2104-5-19**] 07:28 pm 20 gauge - [**2104-5-19**] 07:29 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: dnr/dni disposition:",1
220,"chief complaint: 24 hour events: - weaning off oxygen from face tent down to nasal cannula - no events allergies: clindamycin unknown; last dose of antibiotics: cefipime - [**2104-5-19**] 10:07 pm metronidazole - [**2104-5-19**] 10:40 pm infusions: other icu medications: other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2104-5-20**] 05:50 am vital signs hemodynamic monitoring fluid balance 24 hours since [**06**] am tmax: 37.3 c (99.2 tcurrent: 35.8 c (96.5 hr: 67 (65 - 92) bpm bp: 129/55(74) {102/41(57) - 175/75(83)} mmhg rr: 22 (15 - 29) insp/min spo2: 97% heart rhythm: sr (sinus rhythm) total in: 153 ml po: tf: ivf: 153 ml blood products: total out: 2,000 ml 0 ml urine: ng: stool: drains: balance: -1,847 ml 0 ml respiratory support o2 delivery device: nasal cannula, aerosol-cool ventilator mode: cpap/psv vt (spontaneous): 577 (476 - 577) ml ps : 5 cmh2o rr (spontaneous): 28 peep: 5 cmh2o fio2: 40% pip: 8 cmh2o spo2: 97% abg: ///28/ ve: 12.9 l/min physical examination general: lying in bed at 10 degrees, nad, speaking in complete sentences heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: unlabored respirations, decreased breath sounds bases, crackles bibasilarly, no wheezes/rhonchi cv: s1, s2 regular rhythm, normal rate abdomen: soft, ntnd, no gaurding gu: no foley ext: no edema, lue fistula erythema, warmth, palpable thrill labs / radiology 223 k/ul 12.2 g/dl 130 mg/dl 5.8 mg/dl 28 meq/l 5.1 meq/l 32 mg/dl 96 meq/l 139 meq/l 40.0 % 10.1 k/ul [image002.jpg] [**2104-5-20**] 03:29 am wbc 10.1 hct 40.0 plt 223 cr 5.8 tropt 0.10 glucose 130 ck / ckmb / troponin-t:28//0.10, differential-neuts:88.7 %, lymph:8.6 %, mono:1.9 %, eos:0.2 %, lactic acid:0.9 mmol/l, ca++:9.1 mg/dl, mg++:1.9 mg/dl, po4:5.0 mg/dl micro: [**2104-5-19**]: - gram positive cocci in clusters 2/2 bottles assessment and plan assessment: [**age over 90 382**]m with history of alzheimer's dementia, hypertension, esrd on hd (m/w/f), history of aspiration pneumonia with hypoxemia and fever at hemodialysis found to have gram positive cocci bacteremia. . plan: . # gram positive cocci bacteremia: the most likely site of infection is the av graft site given erythema, warmth on exam and recent instrumentation. most likely due to direct contamination of access site rather than bacteremia with hematogenous seeding. pneumonia also considered given hypoxemia although chest film more consistent with pulmonary edema than infection. - f/u speciation and sensitivity - daily blood cultures - tte to evaluate for vegetations - continue vancomycin for now pending speciation - low threshold to change to daptomycin given history of vre - thoracic surgery consult - discuss hd access with renal - consider id consult - elevate the arm . #hypoxemia: the differential diagnosis includes pulmonary edema/volume overload, aspiration pneumonia, bronchospasm, pneumothorax. there is likely significant contribution from pulmonary edema in the setting missing hemodialysis and uncontrolled hypertension in setting of diastolic heart failure. pneumonia, in particular aspiration pneumonia, is considered given patient history, fever, and leukocytosis although no clear evidence of infiltrate on imaging. pneumothorax is unlikely given evidence of lung shadowing in right apical field on imaging. given rash following administration of clindamycin, bronchospasm and upper airway edema are considered although no evidence of wheezing or stridor on exam. cardiac enzymes negative. reduced oxygen requirement overnight s/p removal of 2l of fluid at hd, currently sating in high 90s on nc- - treat for hcap with vanco, cefipime (id approval in am) - flagyl to cover aspiration - sputum culture, legionella culture - wean bipap after volume removal of 2l as per renal - f/u thoracic surgery recommendations (anticipate nothing new this am) - mechanical soft diet given aspiration risk . # esrd: - renal recs - hd m/w/f schedule - may need temporary access given concern for infection overlying fistula site - continue calcium acetate tid with meals . #fever: differential includes cellulitis/av fistula infection, pulmonary infection. most likely source of infection is av fistula site given physical exam. pneumonia considered given hypoxemia although cxr more c/w pulmonary edema with interval improvement following hd. c. difficile associated disease considered although no history of diarrhea. - blood cultures - sputum cultures - vanco/cefepime/flagyl for now - check stool c. diff . #hyperkalemia: likely due to end stage renal disease in setting of missing hemodialysis session today. no ekg changes. normalized s/p hemodialysis. . #hypertension: most likely secondary to volume overload in the setting of not taking home antihypertensives medications today. no evidence of end organ ischemia clinically or by labs. patient weaned off nitro gtt overnight, currently normotensive on home medications. - start amlodipine, midodrine, metoprolol, and lisinopril .. # acute on chronic diastolic chf: most recent tte was in [**2102**] showing normal systolic function (ef>55%) but moderate diastolic dysfunction. patient with volume overload clinically and by labs with elevated bnp and on imaging with pulmonary edema. likely exacerbated by volume overload in the setting of missing hemodialysis and uncontrolled htn. - continue metoprolol, ccb, and lisinopril . # allergic reaction? patient currently has no rash, no evidence of bronchospasm or upper airway edema. given dose of steroids in ed. - list clindamycin as adverse reaction - no indication to continue steroids at this time . #mental status: patient is aox0 at baseline with poor short-term memory and known alzheimer's dementia. currently appears at baseline. - haldol prn agitation - anticipate some delerium with infection. . # cad? on aspirin. unclear if [**age over 90 52**] y/o dm m warrants asa for primary prevention. . # fen: replete electrolytes, npo tonight then mechanical soft diet # prophylaxis: subcutaneous heparin # access: peripherals # communication: daughter [**name (ni) **] ([**telephone/fax (1) 12197**]) # code: dnr/dni # disposition: icu pending clinical improvement icu care nutrition: glycemic control: lines: 18 gauge - [**2104-5-19**] 07:28 pm 20 gauge - [**2104-5-19**] 07:29 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: full code disposition:",1
221,"chief complaint: 24 hour events: - weaning off oxygen from face tent down to nasal cannula - no events allergies: clindamycin unknown; last dose of antibiotics: cefipime - [**2104-5-19**] 10:07 pm metronidazole - [**2104-5-19**] 10:40 pm infusions: other icu medications: other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2104-5-20**] 05:50 am vital signs hemodynamic monitoring fluid balance 24 hours since [**06**] am tmax: 37.3 c (99.2 tcurrent: 35.8 c (96.5 hr: 67 (65 - 92) bpm bp: 129/55(74) {102/41(57) - 175/75(83)} mmhg rr: 22 (15 - 29) insp/min spo2: 97% heart rhythm: sr (sinus rhythm) total in: 153 ml po: tf: ivf: 153 ml blood products: total out: 2,000 ml 0 ml urine: ng: stool: drains: balance: -1,847 ml 0 ml respiratory support o2 delivery device: nasal cannula, aerosol-cool ventilator mode: cpap/psv vt (spontaneous): 577 (476 - 577) ml ps : 5 cmh2o rr (spontaneous): 28 peep: 5 cmh2o fio2: 40% pip: 8 cmh2o spo2: 97% abg: ///28/ ve: 12.9 l/min physical examination general: lying in bed at 10 degrees, nad, speaking in complete sentences heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: unlabored respirations, decreased breath sounds bases, crackles bibasilarly, no wheezes/rhonchi cv: s1, s2 regular rhythm, normal rate abdomen: soft, ntnd, no gaurding gu: no foley ext: no edema, lue fistula erythema, warmth, no obvious fluctuance, + palpable thrill labs / radiology 223 k/ul 12.2 g/dl 130 mg/dl 5.8 mg/dl 28 meq/l 5.1 meq/l 32 mg/dl 96 meq/l 139 meq/l 40.0 % 10.1 k/ul [image002.jpg] [**2104-5-20**] 03:29 am wbc 10.1 hct 40.0 plt 223 cr 5.8 tropt 0.10 glucose 130 ck / ckmb / troponin-t:28//0.10, differential-neuts:88.7 %, lymph:8.6 %, mono:1.9 %, eos:0.2 %, lactic acid:0.9 mmol/l, ca++:9.1 mg/dl, mg++:1.9 mg/dl, po4:5.0 mg/dl micro: [**2104-5-19**]: - gram positive cocci in clusters 2/2 bottles assessment and plan assessment: [**age over 90 382**]m with history of alzheimer's dementia, hypertension, esrd on hd (m/w/f), history of aspiration pneumonia with hypoxemia and fever at hemodialysis found to have gram positive cocci bacteremia. . plan: . # gram positive cocci bacteremia: the most likely site of infection is the cellulitis overlying av fistula site given erythema, warmth on exam and recent instrumentation. question whether av fistula site infection although no obvious fluctuance on exam. pneumonia also considered given hypoxemia although chest film more consistent with pulmonary edema than infection. - f/u speciation and sensitivity - daily blood cultures - tte to evaluate for vegetations - continue vancomycin for now pending speciation - low threshold to change to daptomycin given history of vre - thoracic surgery consult - discuss hd access with renal - consider id consult - elevate the arm . #hypoxemia: the differential diagnosis includes pulmonary edema/volume overload, aspiration pneumonia, bronchospasm, pneumothorax. there is likely significant contribution from pulmonary edema in the setting missing hemodialysis and uncontrolled hypertension in setting of diastolic heart failure. pneumonia, in particular aspiration pneumonia, is considered given patient history, fever, and leukocytosis although no clear evidence of infiltrate on imaging. pneumothorax is unlikely given evidence of lung shadowing in right apical field on imaging. given rash following administration of clindamycin, bronchospasm and upper airway edema are considered although no evidence of wheezing or stridor on exam. cardiac enzymes negative. reduced oxygen requirement overnight s/p removal of 2l of fluid at hd, currently sating in high 90s on nc- - treat for hcap with vanco, cefipime (id approval in am) - flagyl to cover aspiration - sputum culture, legionella culture - wean bipap after volume removal of 2l as per renal - f/u thoracic surgery recommendations - mechanical soft diet given aspiration risk . # esrd: - renal recs - hd m/w/f schedule - discuss utility of access site given concern for infection with renal/transplant surgery - continue calcium acetate tid with meals . #fever: differential includes cellulitis/av fistula infection, pulmonary infection. most likely source of infection is av fistula site given physical exam. pneumonia considered given hypoxemia although cxr more c/w pulmonary edema with interval improvement following hd. c. difficile associated disease considered although no history of diarrhea. - blood cultures - sputum cultures - vanco/cefepime/flagyl for now - check stool c. diff . #hyperkalemia: likely due to end stage renal disease in setting of missing hemodialysis session today. no ekg changes. normalized s/p hemodialysis. . #hypertension: most likely secondary to volume overload in the setting of not taking home antihypertensives medications today. no evidence of end organ ischemia clinically or by labs. patient weaned off nitro gtt overnight, currently normotensive on home medications. - start amlodipine, midodrine, metoprolol, and lisinopril .. # acute on chronic diastolic chf: most recent tte was in [**2102**] showing normal systolic function (ef>55%) but moderate diastolic dysfunction. patient with volume overload clinically and by labs with elevated bnp and on imaging with pulmonary edema. likely exacerbated by volume overload in the setting of missing hemodialysis and uncontrolled htn. - continue metoprolol, ccb, and lisinopril . # allergic reaction? patient currently has no rash, no evidence of bronchospasm or upper airway edema. given dose of steroids in ed. - list clindamycin as adverse reaction - no indication to continue steroids at this time . #mental status: patient is aox0 at baseline with poor short-term memory and known alzheimer's dementia. currently appears at baseline. - haldol prn agitation - anticipate some delerium with infection. . # cad? on aspirin. unclear if [**age over 90 52**] y/o dm m warrants asa for primary prevention. . # fen: replete electrolytes, npo tonight then mechanical soft diet # prophylaxis: subcutaneous heparin # access: peripherals # communication: daughter [**name (ni) **] ([**telephone/fax (1) 12197**]) # code: dnr/dni # disposition: icu pending clinical improvement icu care nutrition: glycemic control: lines: 18 gauge - [**2104-5-19**] 07:28 pm 20 gauge - [**2104-5-19**] 07:29 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: full code disposition:",1
222,"chief complaint: fever at hemodialysis hpi: 90m with medical history of alzheimer's dementia, hypertension, esrd on hd (m/w/f), history of aspiration pneumonia found to have temperature of 101 at hemodialysis this morning. he underwent a revision of left forearm av fistula on [**2104-4-26**] for two aneurysmal areas with skin ulceration but recently seen by transplant surgery and felt fine to use. last underwent hd on friday, which was unremarkable, but felt chills after. over the weekend he was afebrile, no cough, sob, no increased sputum production (question whether given chocolate and had aspiration). he is aox0 at baseline and per the daughter mental status is at baseline. . in the ed, initial vs were: t 101 hr 86 126/65 20 97% on 3l (no o2 at home). exam with decreased breath sounds bilaterally. wbc of 14.2. cxr initially concerning for possible right apical pneumothorax. thoracic surgery was consulted recommending repeat cxr to evaluate for ptx stability and possible if interval increase will place pigtail. final cxr read as no pneumothorax (skin fold presents mimic) but with small bilateral pleural effusions and moderate pulmonary edema without definite consolidation. he received one dose of clindamycin, vancomycin, and ceftazadine. ? rash to clindamycin so given solumedrol, tylenol. benadryl held given h/o benadryl allergy. potassium of 6.2, ekg without peak t-waves. he was given 30pr of kayexcelate for hyperkalemia. signout was being given to medicine floor team but in worsening respiratory distress requiring bipap and hypertensive (180/50) requiring nitro gtt so transferred to micu. . on the floor, patient without complaint. denies sob, cough. answering questions appropriately. patient admitted from: [**hospital1 54**] er history obtained from patient, family / friend allergies: clindamycin unknown; last dose of antibiotics: cefipime - [**2104-5-19**] 10:07 pm metronidazole - [**2104-5-19**] 10:40 pm infusions: other icu medications: other medications: past medical history: family history: social history: # htn # esrd hd [**2099**] (hypertensive nephropathy), receives hd qmwf # alzheimer's dementia on donepezil(recently discontinued [**3-4**] nocturnal wakenings) # mssa bacteremia treated with 8 weeks iv cefazolin [**10-8**] # pseudomonas bacteremia [**11-7**] rx w/ cipro at va # c. difficile colitis [**11-7**] # bladder ca s/p resection at 60, 83 y/o. most recent resection [**2102-11-20**] - followed w/ yearly cystoscopies as now anuric # aortic ulcerations [**3-9**], unchanged on [**2101-9-25**] abd ct # temporary hd catheter line infection with mssa in [**3-9**], rx with nafcillin, cathether has since been removed # additional episode of mssa bacteremia [**9-6**], unclear source. rx'ed with nafcillin and 4 wks of outpt cefazolin # chronic low back pain # chronic diastolic chf [**2104-4-26**] aneurysmorrhaphy x2 of left arteriovenous fistula. cad brothers (2), mom esrd (unknown etiology) occupation: supervisor of flight kitchen (retired) drugs: none tobacco: none alcohol: none other: lives at [**hospital 169**] [**hospital 12195**] nursing and rehab center ([**telephone/fax (1) 12196**]) review of systems: flowsheet data as of [**2104-5-20**] 12:35 am vital signs hemodynamic monitoring fluid balance 24 hours since [**06**] am tmax: 37.3 c (99.2 tcurrent: 37 c (98.6 hr: 84 (83 - 92) bpm bp: 138/56(77) {125/50(72) - 175/75(83)} mmhg rr: 22 (21 - 28) insp/min spo2: 98% heart rhythm: sr (sinus rhythm) total in: 153 ml po: tf: ivf: 153 ml blood products: total out: 2,000 ml 0 ml urine: ng: stool: drains: balance: -1,847 ml 0 ml respiratory o2 delivery device: aerosol-cool ventilator mode: cpap/psv vt (spontaneous): 577 (476 - 577) ml ps : 5 cmh2o rr (spontaneous): 28 peep: 5 cmh2o fio2: 50% pip: 8 cmh2o spo2: 98% ve: 12.9 l/min physical examination vitals: 99.2 170/58 87 bipap 8/5 60%fio2 99% 20 general: lying in bed at 10 degrees, nad heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: unlabored respirations, decreased breath sounds bases, crackles bibasilarly, no wheezes/rhonchi cv: s1, s2 regular rhythm, normal rate abdomen: soft, ntnd, no gaurding gu: no foley ext: no edema, lue fistula sight erythema, crusting, no drainage labs / radiology [image002.jpg] other labs: lactic acid:0.9 mmol/l assessment and plan 90m with history of alzheimer's dementia, hypertension, esrd on hd (m/w/f), history of aspiration pneumonia with hypoxemia and fever at hemodialysis. . plan: . #hypoxemia: the differential diagnosis includes pulmonary edema/volume overload, aspiration pneumonia, bronchospasm, pneumothorax. there is likely significant contribution from pulmonary edema in the setting missing hemodialysis and uncontrolled hypertension in setting of diastolic heart failure. pneumonia, in particular aspiration pneumonia, is considered given patient history, fever, and leukocytosis although no clear evidence of infiltrate on imaging. pneumothorax is unlikely given evidence of lung shadowing in right apical field on imaging. given rash following administration of clindamycin, bronchospasm and upper airway edema are considered although no evidence of wheezing or stridor on exam. - treat for hcap with vanco, cefipime (id approval in am) - flagyl to cover aspiration - sputum culture, legionella culture - wean bipap after volume removal of 2l as per renal - appreciate thoracic's rec's - repeat cxr now and in am. - wean nitro gtt - serial ce's (repeat in am) - mechanical soft diet given aspiration risk . #fever: differential includes cellulitis/av fistula infection, pulmonary infection. the av fistula site erythema and crusting post-surgical revision are concerning although av fistula infections are not common, with most common pathogen being sta staphylococcus. pneumonia considered given hypoxemia although chest film more consistent with pulmonary edema than infection. c. difficile associated disease considered although no history of diarrhea. - repeat cxr in am post-hd - transplant surgery in am to formerly evaluate av fistula (reportedly saw in ed and ok d use of fistula for hd) - blood cultures - vanco/cefepime/flagyl for now - consider change vancomycin to daptomycin if clinically deteriorates given history of vre - elevate the arm - check stool c. diff . #hyperkalemia: likely due to end stage renal disease in setting of missing hemodialysis session today. no ekg changes. - hemodialysis now - repeat k+ post hd . #hypertension: most likely secondary to volume overload in the setting of not taking home antihypertensives medications today. no evidence of end organ ischemia clinically or by labs. - start amlodipine - start minoxidil - start metoprolol - start lisinopril - wean off nitro gtt during hemodialysis as long as sbp<160 . # acute on chronic diastolic chf: most recent tte was in [**2102**] showing normal systolic function (ef>55%) but moderate diastolic dysfunction. patient with volume overload clinically and by labs with elevated bnp and on imaging with pulmonary edema. likely exacerbated by volume overload in the setting of missing hemodialysis and uncontrolled htn. - hemodialysis today - continue metoprolol, ccb, and lisinopril . # allergic reaction? patient currently has no rash, no evidence of bronchospasm or upper airway edema. given dose of steroids in ed. - list clindamycin as adverse reaction - no indication to continue steroids at this time . #mental status: patient is aox0 at baseline with poor short-term memory and known alzheimer's dementia. currently appears at baseline. - haldol prn agitation - anticipate some delerium with infection. . # esrd: - renal recs - hd m/w/f schedule - continue calcium acetate tid with meals . # cad? on aspirin. unclear if [**age over 90 52**] y/o dm m warrants asa for primary prevention. . # fen: replete electrolytes, npo tonight then mechanical soft diet # prophylaxis: subcutaneous heparin # access: peripherals # communication: daughter [**name (ni) **] ([**telephone/fax (1) 12197**]) # code: dnr/dni # disposition: icu pending clinical improvement icu care nutrition: glycemic control: lines: 18 gauge - [**2104-5-19**] 07:28 pm 20 gauge - [**2104-5-19**] 07:29 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: full code disposition:",1
223,"chief complaint: transfer to ccu for respiratory distress 24 hour events: [**2165-5-6**]: -3 a.m.: had luq pain. received morphine 0.5 mg po -5:30 a.m., went into afib with normal hr and bp and no other ekg changes -spoke with dr. [**last name (stitle) 2759**]: stopped lasix gtt, free water restrict to 1500 cc daily -gave isordil 10 mg once po tonight (not given imdur or felodipine this a.m. given that she had twice normal carvedilol) just to cover cad until a.m. - stopped nac given no renal artery stent for now. - na corrected by 6 over 12 hours, k 3.7 but cr 4.2 (didn't replete) allergies: atorvastatin muscle/bone pai tylenol (oral) (dm hb/pseudoephed/acetamin/cp) muscle pain; ibuprofen muscle/bone pai rosuvastatin abdominal pain; last dose of antibiotics: infusions: other icu medications: other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2165-5-7**] 07:43 am vital signs hemodynamic monitoring fluid balance 24 hours since [**67**] am tmax: 36.6 c (97.8 tcurrent: 36.6 c (97.8 hr: 63 (51 - 84) bpm bp: 134/50(70) {112/42(62) - 134/58(73)} mmhg rr: 18 (12 - 24) insp/min spo2: 94% heart rhythm: sr (sinus rhythm) wgt (current): 47.7 kg (admission): 47.1 kg total in: 775 ml 120 ml po: 640 ml 120 ml tf: ivf: 135 ml blood products: total out: 1,460 ml 640 ml urine: 1,460 ml 640 ml ng: stool: drains: balance: -685 ml -520 ml respiratory support o2 delivery device: nasal cannula spo2: 94% abg: ///32/ physical examination peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) skin: not assessed neurologic: responds to: not assessed, movement: not assessed, tone: not assessed labs / radiology 305 k/ul 9.0 g/dl 137 mg/dl 4.2 mg/dl 32 meq/l 3.7 meq/l 112 mg/dl 81 meq/l 129 meq/l 26.2 % 6.6 k/ul [image002.jpg] [**2165-5-6**] 12:48 am [**2165-5-6**] 04:08 pm [**2165-5-7**] 06:02 am wbc 7.4 6.6 hct 25.7 26.2 plt 239 305 cr 4.4 4.2 tropt 0.20 glucose 137 other labs: pt / ptt / inr:13.1/26.5/1.1, ck / ckmb / troponin-t:17//0.20, albumin:3.6 g/dl, ca++:9.2 mg/dl, mg++:3.8 mg/dl, po4:5.8 mg/dl imaging: none microbiology: none assessment and plan altered mental status (not delirium) .h/o renal failure, chronic (chronic renal failure, crf, chronic kidney disease) pain control (acute pain, chronic pain) .h/o heart failure (chf), systolic and diastolic, acute on chronic [**age over 90 52**]yo woman with h/o cad s/p pci, systolic chf with ef of 40%, and chronic kidney disease who is transferred to the ccu with respiratory distress. . # respiratory distress: the working diagnosis has been that the patient has pulmonary edema due to acute on chronic systolic heart failure. however, it is also possible that the patient actually has a pneumonia explaining her worsened respiratory status, possibly in the setting of aspiration (although no specific aspiration event was observed). for now, we will continue to treat for pulmonary edema. - confirmed that patient is okay to intubate if necessary - consider restarting lasix 80mg po bid per renal pt very volume sensitive and requires some diuresis - dr. [**last name (stitle) **] deferring on renal artery stent for now - albuterol and ipratropium nebs . # altered mental status: most likely related to patient s hyponatremia. differential diagnosis includes infection, uremia, meds. - treat hyponatremia as below - minimize sedating meds . # hyponatremia: unclear if this is hypervolemic hypernatremia in setting of chf or siadh in the setting of a pulmonary process. urine lytes and osms may help to clarify this issue, although urine osm may be difficult to interpret in the setting of ongoing diuresis with furosemide. - f/u urine lytes - pending . # abdominal pain: etiology unclear. bowel sounds present. - f/u on radiology read of kub - ensure adequate bowel regimen . # acute on chronic kidney injury chronic kidney disease: baseline cr 2.4-2.8 recently, current 4.3. the patient has atrophic right kidney and left renal artery stenosis. there has been discussion of possible stent of renal artery on [**5-6**]. patient s recent decline in kidney function is likely related to poor renal perfusion. atn is also possible. - check urine lytes - monitor for signs and symptoms of uremia - n-acetylcysteine dc - no stenting for now. # cad s/p bms to lcx [**2165**]: no evidence of active ischemia - continue asa 162 and plavix - continue carvedilol . # anemia: baseline hct 28-30, current hct 25.7: hct has been slowly trending down during course of her admission. underlying cause of her anemia is likely her renal failure, but unclear why her hct should be trending down. stable. - recheck hct - maintain active type and screen - if continues to fall, will check hemolysis labs . # neck and back pain: although she has atherosclerotic disease, she is not hypertensive and does not have a widened mediastinum. her exam is consistent with musculoskeletal causes of pain. - note that she has adverse reaction (increased pain) to tylenol and ibuprofen - warm packs prn - lidocaine patch # hypertension: normotensive - continue felodipine per home regimen - will continue carvedilol (note that dose has been doubled from home dose of 12.5mg [**hospital1 **]) - holding hydralazine - would aim for sbps 120s-130s - continue isosorbide # hyperlipidemia: has not tolerated many statins # type 2 diabetes: diet-controlled. - insulin sliding scale (gentle) # gerd: continue famotidine 20 mg tablet per outpatient regimen icu care nutrition: diabetic, low salt diet; npo p mn for possible stent glycemic control: lines: 20 gauge - [**2165-5-5**] 10:30 pm 22 gauge - [**2165-5-5**] 10:35 pm prophylaxis: dvt: subq heparin stress ulcer: vap: comments: communication: comments: daughter [**name (ni) 3112**] is hcp: [**telephone/fax (1) 11993**] code status: dnr but okay to intubate disposition: ccu",1
224,"title: chief complaint: shortness of breath hpi: ms. [**known lastname 11794**] is a [**age over 90 52**]yo woman with h/o cad s/p bms to lcx, systolic heart failure with ef of 40%, and chronic kidney disease who initially presented [**4-29**] with chest pain and is currently being transferred to the ccu for shortness of breath and hypoxia. briefly, ms. [**known lastname 11794**] was recently admitted to the [**hospital unit name 44**] [**date range (1) 11991**], where she was intubated for hypoxic respiratory failure due to heart failure. she was discharged to [**hospital 12**] rehab, where she was reportedly doing well until she developed chest pain associated with nausea and backache. per prior notes, these symptoms were reminscent of how she felt when she had acute coronary syndrome in the past. she was admitted to the cardiology service and ruled out for an mi. when her bnp was found to be > 45,000 (value was 32,000 during [**hospital unit name 44**] stay), the team entertained the possibility that chf exacerbation might be an explanation of her symptoms, though cxr only showed cardiomegaly but no vascular congestion. her bp meds were titrated up and she was given iv lasix for diuresis. between [**date range (1) 11992**], she received escalating doses of iv lasix +/- metolazone for episodes of shortness of breath. in addition, her hydralazine and imdur doses were increased. interestingly, she never desaturated during this time and her cxrs were not read as being consistent with pulmonary edema. during this time, her cr increased from 2.9 to 3.6. she was briefly on a lasix gtt during [**5-3**], but this was stopped in the setting of poor urine output and a cr of 3.8. over the subsequent two days, all diuretics were stopped. today, she was complaining of chest pain and upper back pain. in addition, she began feeling increasingly short of breath and was noted to be tachypneic into the 20s. she triggered for nursing concern. an abg on 2l of nasal cannula showed: 7.48/46/62 and a cxr showed findings consistent with pulmonary edema as well as b/l lower lobe opacities. she received lasix 120mg iv and nitropaste. two hours later, her next nurse was called into the room to evaluate chest pain. the patient was noted be hypoxic to 89% on 3.5l and be newly disoriented, causing a second trigger for nursing concern. she was placed on a non-rebreather with improvement in her sat's to 100%. per discussion with the cardiology attending, the patient was transferred to the ccu for further care. upon arrival to the ccu, the patient was sleepy but rousable. she endorsed substernal chest pain and pain in her upper back. at one point she stated she ""could not catch"" her breath, though later she denied feeling short of breath. on review of systems, she denies any prior history of stroke, tia, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. she denies recent fevers, chills or rigors. she denies exertional buttock or calf pain. all of the other review of systems were negative. cardiac review of systems is notable for absence of ankle edema, palpitations, syncope or presyncope. allergies: atorvastatin muscle/bone pai tylenol (oral) (dm hb/pseudoephed/acetamin/cp) muscle pain; ibuprofen muscle/bone pai rosuvastatin abdominal pain; last dose of antibiotics: infusions: furosemide (lasix) - 10 mg/hour other icu medications: furosemide (lasix) - [**2165-5-5**] 11:15 pm other medications: medications (based on dc paperwork [**4-24**]): aspirin 162mg daily clopidogrel 75 mg daily hydralazine 10 mg q6hr isosorbide mononitrate 20 mg [**hospital1 **] felodipine 10 mg daily carvedilol 12.5 mg [**hospital1 **] furosemide 40 mg tablet [**hospital1 **] nitrostat 0.4 mg tablet, sublingual prn senna 8.6 mg [**hospital1 **] famotidine 20 mg tablet calcitriol 0.25 mcg capsule po qmowefr cyanocobalamin 500 mcg daily docusate sodium 100 mg [**hospital1 **] iron (ferrous sulfate) 325 mg daily . . meds on transfer: nitroglycerin ointment 2% 1 inch tp once furosemide 120 mg iv once duration x 1 morphine sulfate 0.5 mg iv x 2 doses on [**5-5**] acetylcysteine 20% 600 mg po/ng [**hospital1 **] duration: 4 doses (first dose on [**5-5**] in pm) morphine sulfate (oral soln.) 0.5 mg po/ng q6h:prn pain lidocaine 5% patch 2 ptch td 12 hours on, 12 hours off calcium acetate 667 mg po tid w/meals isosorbide mononitrate (extended release) 90 mg po daily albuterol 0.083% neb soln 1 neb ih q6h:prn shortness of breath nitroglycerin sl 0.3 mg sl prn chest pain carvedilol 25 mg po/ng [**hospital1 **] aluminum-magnesium hydrox.-simethicone 15-30 ml po/ng qid:prn heparin 5000 unit sc tid bisacodyl 10 mg po/pr daily:prn constipation felodipine 10 mg po daily aspirin 325 mg po/ng daily clopidogrel 75 mg po/ng daily docusate sodium 100 mg po bid senna 1 tab po/ng [**hospital1 **]:prn constipation famotidine 20 mg po/ng q24h past medical history: family history: social history: # cad - s/p nstemi [**9-16**] medically managed; and another nstemi [**3-20**] with bms to lcx. # chronic systolic/diastolic congestive heart failure, ef 40% # chronic kidney disease with atrophic right kidney - followed by dr [**last name (stitle) 2759**], cr increasing from 2.0 since [**2165-3-11**] # hypertension # hyperlipidemia, intolerant of several statins # type 2 diabetes, diet-controlled. last a1c 6.1% in [**5-17**] # anemia with baseline hct 27-30 # gerd # h/o breast cancer - diagnosed in [**2145**], s/p lumpectomy # s/p total abdominal hysterectomy [**2094**] for fibroids # cataracts # possible copd -- cxr findings suggestive, no significant smoking history cardiac risk factors: +diabetes, +dyslipidemia, +hypertension cardiac history: -cabg: none -percutaneous coronary interventions: [**3-20**]: bms to lcx and successful poba of jailed om1 -pacing/icd: none there is no family history of premature coronary artery disease or sudden death. her father had hypertension. her sister is alive and healthy at 93. until [**2165-2-8**], she was living alone and independently. she did all of her own bills, though her daughter would often bring her meals. she helped do her own laundry and cleaning around the house. there is a very remote history of smoking. no alcohol abuse. review of systems: flowsheet data as of [**2165-5-6**] 01:51 am vital signs hemodynamic monitoring fluid balance 24 hours since [**67**] am tmax: 36.4 c (97.5 tcurrent: 36.4 c (97.5 hr: 63 (63 - 66) bpm bp: 127/48(66) {121/47(65) - 136/57(76)} mmhg rr: 19 (14 - 24) insp/min spo2: 96% heart rhythm: sr (sinus rhythm) total in: 248 ml 18 ml po: tf: ivf: 8 ml 18 ml blood products: total out: 965 ml 140 ml urine: 90 ml 140 ml ng: stool: drains: balance: -718 ml -122 ml respiratory spo2: 96% abg: ///29/ physical examination vs: 97.5 136/57 65 14 (20 to my count) 93% general: elderly woman who is mildly tachypneic but using accessory muscles to breath and exhales against pursed lips. keeps eyes closed but will open them to respond to questions; easily roused. answers that she is ""in [**location (un) **]"" but then corrects that she ""wishes to be in [**location (un) **]."" can give first names of her grandparents and interacts w/ her family appropriately. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple. prominent carotid pulsations and external jugular vein but i am unable to locate her jvp reliably. neck and upper back are sore and feel better when rubbed. cardiac: pmi is not displaced. regular rhythm with normal s1 and s2. no murmurs rubs or gallops appreciated. lungs: +kyphosis. labored respirations with coarse crackles [**2-9**] of the way of her lung fields b/l. no significant wheeze. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. extremities: no lower extremity edema. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: distal pulses are dopplerable b/l. labs / radiology 239 k/ul 8.9 g/dl 137 mg/dl 4.4 mg/dl 108 mg/dl 29 meq/l 3.8 meq/l 25.7 % 7.4 k/ul [image002.jpg] [**2161-2-9**] 2:33 a3/29/[**2165**] 12:48 am [**2161-2-13**] 10:20 p [**2161-2-14**] 1:20 p [**2161-2-15**] 11:50 p [**2161-2-16**] 1:20 a [**2161-2-17**] 7:20 p 1//11/006 1:23 p [**2161-3-12**] 1:20 p [**2161-3-12**] 11:20 p [**2161-3-12**] 4:20 p wbc 7.4 hct 25.7 plt 239 cr 4.4 glucose 137 other labs: pt / ptt / inr:13.1/26.5/1.1, ca++:9.2 mg/dl, mg++:3.6 mg/dl, po4:5.8 mg/dl ekg: sinus bradycardia at 54 with lbbb. there are q waves in iii and avf. telemetry: sinus rhythm in the 60s 2d-echocardiogram [**2165-3-11**]: the left atrium is mildly dilated. a left-to-right shunt across the interatrial septum is seen at res c/w a small secundum atrial septal defect. there is mild symmetric left ventricular hypokinesis of the distal half of the septum and anterior walls and apex . the remaining segments contract normally (lvef = 40 %). the estimated cardiac index is normal (>=2.5l/min/m2). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. impression: mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w cad. moderate mitral regurgitation. mild pulmonary artery systolic hypertension. small secundum type atrial septal defect. compared with the prior study (images reviewed) of [**2164-12-5**], septal dysfunction is slightly more prominent and a secundum type atrial septal defect is more clearly defined. the severity of mitral regurgitation is similar and was underestimated on the prior study. cardiac cath [**3-/2165**]: 1. selective coronary angiography in this left dominant system demonstrated single vessel disease. the lmca had a 40% diffuse narrowing. the lad had an ostial 50% diffuse stenosis, a 40% proximal stenosis and total occlusion mid-vessel wil distal filling via collaterals. the lcx had a proximal 80% lesion at om1. om2 and om3 were free of disease. the rca was small and non-dominant with an 80% stenosis involving the acute marginal. 2. severe systemic hypertension was noted with sbp 168 mm hg and dbp 50mm hg. 3. angiography revealed diffuse, bulky and ulcerated plaques in the distal aorta. 4. successful ptca and stenting of the mid lcx with a 3.0 x 18mm vision bare metal stent. final angiography revealed a 10% residual stenosis, no angiographically apparent dissection, and timi 3 flow. 5. successful ptca of the jailed om1 origin with a 1.5 x 9mm maverick balloon. final angiography revealed a 50% residual stenosis, no angiographically apparent dissection, and timi 3 flow. (see ptca comments for details) 6. ivus of the lmca revealed 6.8mm2 mla indicating a non-hemodynamically significant stenosis. final diagnosis: 1. single vessel coronary artery disease. 2. systemic hypertension. 3. successful ptca and stenting of the mid lcx. 4. successful ptca of the jailed om1. 5. ivus of lmca with mla of 6.8mm2. cxr [**2165-5-5**]: 1. worsening pulmonary edema and increasing small pleural effusions. 2. bilateral lower lobe airspace opacities, which may be due to dependent areas of pulmonary edema or superimposed secondary process such as aspiration or infectious pneumonia. followup radiographs after diuresis may be helpful in this regard. assessment and plan [**age over 90 52**]yo woman with h/o cad s/p pci, systolic chf with ef of 40%, and chronic kidney disease who is transferred to the ccu with respiratory distress. # respiratory distress: ms. [**known lastname 11794**] likely has pulmonary edema due to acute on chronic systolic heart failure. it is odd that her initial cxr did not show evidence of vascular congestion and that subsequent cxrs in the hospital have actually worsened despite increasing doses of diuresis (though perhaps she has not really diuresed in response to this lasix). moreover, she has not had documented acute hypertension prior to her episodes of ""flashing."" other possible causes of her worsening tachypnea and hypoxia include aspiration pneumonitis or undiagnosed copd. she has been in the company of her daughter almost all day and no aspiration events have been witnessed. also, she likely has some age-related emphysematous changes but does not have a strong enough smoking history to suggest copd. finally, it is intriguing that she has an asd, though i cannot explain how diuresis might cause the shunt to go from right to left and i would expect her to be more markedly hypoxic were that the mechanism of her respiratory distress. - confirmed that patient is okay to intubate if necessary - lasix 120mg iv now followed by lasix gtt - will discuss possibility of renal stent vs hemodialysis with drs. [**last name (stitle) 11806**], [**name5 (ptitle) 2759**], and [**doctor last name **] in the morning - would add metolazone to assist with diuresis if necessary - continue hydralazine and isosorbide - atrovent nebs # cad s/p bms to lcx [**2165**]: - continue asa 162 and plavix - continue carvedilol - no evidence of acute ischemia on ekg - will cycle cardiac biomarkers given chest pain # chronic kidney disease: baseline cr 2.4-2.8 recently, current 4.3: note that patient has atrophic right kidney and left renal artery stenosis. there has been discussion of possible stent of renal artery on [**5-6**]. - n-acetylcysteine in anticipation of possible dye load - will discuss options (renal artery stenting, hemodialysis, or comfort-directed care) with patient's providers as discussed above # anemia: baseline hct 28-30, current hct 23.8: hct has been slowly trending down during course of her admission. underlying cause of her anemia is likely her renal failure, but unclear why she might be acutely worse. - recheck hct - maintain active type and screen - if continues to fall, will check hemolysis labs # [**last name (un) **] and back pain: although she has atherosclerotic disease, she is not hypertensive and does not have a widened mediastinum. her exam is consistent with musculoskeletal causes of pain. - note that she has adverse reaction (increased pain) to tylenol and ibuprofen - warm packs prn # hypertension: - continue felodipine per home regimen - will continue carvedilol (note that dose has been doubled from home dose of 12.5mg [**hospital1 **]) - will continue hydralazine (also increased from home dose) - would aim for sbps 120s-130s - isosorbide as above # hyperlipidemia: has not tolerated many statins # type 2 diabetes: diet-controlled. - insulin sliding scale (gentle) # gerd: - continue famotidine 20 mg tablet per outpatient regimen # fen: diabetic, low salt diet; npo p mn for possible stent # access: pivs # prophylaxis: -dvt ppx with subq heparin -pain management with warm packs -bowel regimen with docusate/senna prn # code: dnr but okay to intubate # comm: daughter [**name2 (ni) 3112**] is hcp: [**telephone/fax (1) 11993**] # dispo: ccu for now",1
225,"chief complaint: transfer to ccu for respiratory distress 24 hour events: [**2165-5-6**]: -3 a.m.: had luq pain. received morphine 0.5 mg po -5:30 a.m., went into afib with normal hr and bp and no other ekg changes -spoke with dr. [**last name (stitle) 2759**]: stopped lasix gtt, free water restrict to 1500 cc daily -gave isordil 10 mg once po tonight (not given imdur or felodipine this a.m. given that she had twice normal carvedilol) just to cover cad until a.m. - stopped nac given no renal artery stent for now. - na corrected by 6 over 12 hours, k 3.7 but cr 4.2 (didn't replete) allergies: atorvastatin muscle/bone pai tylenol (oral) (dm hb/pseudoephed/acetamin/cp) muscle pain; ibuprofen muscle/bone pai rosuvastatin abdominal pain; last dose of antibiotics: infusions: other icu medications: other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: no cp, sob, feels well. does have a cough. flowsheet data as of [**2165-5-7**] 07:43 am vital signs hemodynamic monitoring fluid balance 24 hours since [**67**] am tmax: 36.6 c (97.8 tcurrent: 36.6 c (97.8 hr: 63 (51 - 84) bpm bp: 134/50(70) {112/42(62) - 134/58(73)} mmhg rr: 18 (12 - 24) insp/min spo2: 94% heart rhythm: sr (sinus rhythm) wgt (current): 47.7 kg (admission): 47.1 kg total in: 775 ml 120 ml po: 640 ml 120 ml tf: ivf: 135 ml blood products: total out: 1,460 ml 640 ml urine: 1,460 ml 640 ml ng: stool: drains: balance: -685 ml -520 ml respiratory support o2 delivery device: nasal cannula spo2: 94% abg: ///32/ physical examination general: elderly woman who is alert and oriented x 3 neck: supple. prominent carotid pulsations and external jugular vein no ij visualized cardiac: regular rhythm with normal s1 and s2. no murmurs rubs or gallops appreciated. lungs: +kyphosis. decreased breath sounds at bilateral lung bases r>l. with bibasilar rhales and occasional wheeze abdomen: soft, ntnd, +bs extremities: no lower extremity edema. labs / radiology 305 k/ul 9.0 g/dl 137 mg/dl 4.2 mg/dl 32 meq/l 3.7 meq/l 112 mg/dl 81 meq/l 129 meq/l 26.2 % 6.6 k/ul [image002.jpg] [**2165-5-6**] 12:48 am [**2165-5-6**] 04:08 pm [**2165-5-7**] 06:02 am wbc 7.4 6.6 hct 25.7 26.2 plt 239 305 cr 4.4 4.2 tropt 0.20 glucose 137 other labs: pt / ptt / inr:13.1/26.5/1.1, ck / ckmb / troponin-t:17//0.20, albumin:3.6 g/dl, ca++:9.2 mg/dl, mg++:3.8 mg/dl, po4:5.8 mg/dl imaging: none microbiology: none assessment and plan altered mental status (not delirium) .h/o renal failure, chronic (chronic renal failure, crf, chronic kidney disease) pain control (acute pain, chronic pain) .h/o heart failure (chf), systolic and diastolic, acute on chronic [**age over 90 52**]yo woman with h/o cad s/p pci, systolic chf with ef of 40%, and chronic kidney disease who is transferred to the ccu with respiratory distress. . # respiratory distress: the working diagnosis has been that the patient has pulmonary edema due to acute on chronic systolic heart failure. however, it is also possible that the patient actually has a pneumonia explaining her worsened respiratory status, possibly in the setting of aspiration (although no specific aspiration event was observed). for now, we will continue to treat for pulmonary edema. - consider restarting lasix 80mg po bid per renal pt very volume sensitive and requires a maintainance diuretic regimen, chose 80 for now because her gfr is halved, would recommend going down to 40 [**hospital1 **] once gfr improves - dr. [**last name (stitle) **] deferring on renal artery stent for now - albuterol and ipratropium nebs - wean o2 . # altered mental status: improving. most likely related to patient hyponatremia. differential diagnosis includes infection, uremia, meds. - treat hyponatremia as below - minimize sedating meds . # hyponatremia: unclear if this is hypervolemic hypernatremia in setting of chf or siadh in the setting of a pulmonary process. urine lytes and osms may help to clarify this issue, although urine osm may be difficult to interpret in the setting of ongoing diuresis with furosemide. - f/u urine lytes - pending . # abdominal pain: resolved. etiology unclear. bowel sounds present. - f/u on radiology read of kub - ensure adequate bowel regimen . # acute on chronic kidney injury chronic kidney disease: baseline cr 2.4-2.8 recently, current 4.3. the patient has atrophic right kidney and left renal artery stenosis. there has been discussion of possible stent of renal artery on [**5-6**]. patient s recent decline in kidney function is likely related to poor renal perfusion. atn is also possible. - check urine lytes - monitor for signs and symptoms of uremia - n-acetylcysteine dc - no stenting for now. # cad s/p bms to lcx [**2165**]: no evidence of active ischemia - continue asa 162 and plavix - continue carvedilol . # anemia: baseline hct 28-30, current hct 25.7: hct has been slowly trending down during course of her admission. underlying cause of her anemia is likely her renal failure, but unclear why her hct should be trending down. stable. - monitor hct - maintain active type and screen - if continues to fall, will check hemolysis labs . # neck and back pain: although she has atherosclerotic disease, she is not hypertensive and does not have a widened mediastinum. her exam is consistent with musculoskeletal causes of pain. - note that she has adverse reaction (increased pain) to tylenol and ibuprofen - warm packs prn - lidocaine patch # hypertension: normotensive - continue felodipine per home regimen - will continue carvedilol (note that dose has been doubled from home dose of 12.5mg [**hospital1 **]) - holding hydralazine - would aim for sbps 120s-130s - continue isosorbide # hyperlipidemia: has not tolerated many statins # type 2 diabetes: diet-controlled. - insulin sliding scale (gentle) # gerd: continue famotidine 20 mg tablet per outpatient regimen icu care nutrition: diabetic, low salt diet; npo p mn for possible stent glycemic control: lines: 20 gauge - [**2165-5-5**] 10:30 pm 22 gauge - [**2165-5-5**] 10:35 pm prophylaxis: dvt: subq heparin stress ulcer: vap: comments: communication: comments: daughter [**name (ni) 3112**] is hcp: [**telephone/fax (1) 11993**] code status: dnr but okay to intubate disposition: ccu",1
226,title: respiratory care: rec d pt on psv 12/5/40%. pt has #7 portex trach. bs are mostly clear with occasional rhonchi which clear following suctioning. mdi s alb/atr/qvar as ordered with no adverse reactions. nebs of tobramyacin initiated tonight. some periods noted of tachycardia noc. am abg 7.49/43/95/ rsbi=145 no further changes noc.,0
227,title: respiratory care: rec d pt on psv 12/5/40%. pt has #7 portex trach. bs are mostly clear with occasional rhonchi which clear following suctioning. mdi s alb/atr/qvar as ordered with no adverse reactions. nebs of tobramyacin initiated tonight. some periods noted of tachycardia noc. no further changes noc.,0
228,"64yr old male with h/o prostate and bladder cancer. admitted for cystoprostatectomy on 9/11with creation of neobladder. postop patient developed nausea, vomiting, and diarrhea, kub revealed distended bowel loops with concern for sbo. ct this am showed sbo and incisional hernia, pt. sent back to or for exploration of wound, dehiscence and repair or small bowel obstruction. during procedure urinary output low, sent to [**hospital unit name 1**] for monitoring post surgery. abdominal pain (including abdominal tenderness) assessment: s/p abdominal surgery for sbo. abdominal binder in place with surgical dressing intact beneath. no active oozing or bleeding overnight. action: bs absent at this time, no flatus. abdominal binder remains on. started on dilaudid pca at 0.12mg/hr lockout of 6mins and hour max 1.2mg. pt instructed on use however needs consistent reinforcement. mr. [**known lastname 1884**] does become confused wrt place and time. response: tolerating analgesia well, no adverse reactions noted. rr remains >10bpm. of note patient has most of his discomfort when moving in bed. plan: continue to monitor v/s and frequently assess pain level using pain scale. [**last name **] problem ca of prostate and bladder assessment: s/p cystoprostatectomy on [**8-7**] with creation of neobladder. urinary catheter placed and is not to be removed under any circumstances unless indicated by team/urology. action: foley to be flushed q4hr/prn with 30cc. urinary output low, multiple fluid boluses given overnight see chart for details. response: the need for the catheter to be flushed more frequently, like q2hr noted. continues with pus in the urine, urology is aware and states same is to be expected. if you do not aspiration 30cc as instilled that is fine with urology. however, 30cc has been returned consistently. often times no urinary output without flushing catheter. plan: continue to monitor i&o small bowel obstruction (intestinal obstruction, sbo, including intussusception, adhesions) assessment: s/p exploration and repair of sbo. ngt to continuous low suction with greenish return. action: abdominal binder remains intact. response: patient is afebrile. wound is clean dry and in tact from the out [**hospital1 **] appearance. plan: continue with antibiotic management. vanc, flagy, and levo.",0
229,title: respiratory car: rec d pt on 40% t/c and remained on t/c all night without distress tolerated well. bs are coarse then clear with suctioning or cough. suctioned for small amounts of thick yellow/tannish secretions and was also able to expectorate sputum from trach. pt has a strong cough. mdi s of combivient were administered via trach/ambu as ordered with no adverse reactions. inner cannula checked and clear/ spare inner cannulas in room. speech/swallow study team to evaluate pt for passy /speaking valve today. cuff remains deflated with no distress noted. 02 sats @ 96-97%. will continue to follow. vent pulled.,0
230,"pt admitted to [**hospital 1294**] hospital after being found down by husband. [**name (ni) 186**] is mentally challenged and did not call ems right away so it is reported that pt may have been down for several hours. upon arrival to ed in [**hospital1 1294**] blood sugar was 1400's. rij tl placed and complicated by pneumothorax. right chest tube placed. placed on insulin gtt and admitted to icu. found to have increased liver enzymes, arf and was placed on dialysis. pt had quinton cath in right sc. on [**7-17**] pt was extubated for four hours and then had to be reintubated. u/a found to have [**female first name (un) **], blood cx's negative from osh, cath tip from original fem line shown to have beta strep b from osh. head ct's negative x 2 and abd ct shows small bowel thickened and ascites at osh. ultrasound showed distended gallbladder. pt transferred to [**hospital1 19**] for ? ercp. tbili flat, no indication for ercp at this time. ct removed [**7-25**]. peg/trach/picc line placed [**7-27**] pt. more alert and responsive tonight. sats improving to 100%, at goal for tube feedings. sodium normalizing, repleted potassium alteration in nutrition assessment: abd firm distended, active bt, flexiseal drain mod amt soft stool drk green. tube feeding progressing to goal of 40 cc hr. residuals 30 cc, free water bolus now 250 cc hr. no c/o nausea action: cont. tube feeds at goal 40cc hr, follow residuals closely, cont. flexiseal, response: residuals 30-40 cc hr. now at goal 40 cc hr nutren pulm. site cond. good, abd softer with pos. bt plan: cont. checking residuals freq. tube feeds to cont at goal rate 40 cc hr. , cont. flexiseal line infection (central or arterial) assessment: lab called to note triple lumen grew gr+ cocci in pairs. noted to ho. old line site covered with transparent drsg [**name5 (ptitle) **] [**name5 (ptitle) 1493**] noted, pt afebrile action: monitor wound site. , pt. temps, labs just completed antibiotic coarse. response: no change plan: monitor line site carefully for [**name5 (ptitle) 1493**], respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: good cough effort, thick secretions brwn in color. mod amt. trach site wnl, still some bronchospasm with movement. sats 100% on cpap rr 17-30 when awake. action: pulm toilet, trach cares done, mouth cares, enc. cough and deep breathing. response: improved sats this night. secretions remain thick, plan: wean to trach mask today as able. mobilize follow up on pan culture results as available cardiac dysrhythmia other assessment: pt with irreg irreg hr to 160. no chest pain complaint. bp stable. no further episodes now in sinus to sinus brady 55-70 with some ectopy action: ekg, ho noted. electrolytes drawn response: stable spont converted, no betablockers as adverse reaction to metoprolol and pt. own rate to 60 s with sleep k+ depleted. pt has been autodiuresing this night plan: cont. to monitor, repleted potassium, follow urine output. adjusted free water to 250 cc q 4 hr. ` electrolyte & fluid disorder, other assessment: pt. k= depleted. arrythmias noted no chest pain. sodium normalizing action: total 80 meq kcl divided into 2 doses given this night response: repleted adequately. plan: monitor and replete as needed. free water flush 250 cc q 4 hr",1
231,"pt admitted to [**hospital 1294**] hospital after being found down by husband. [**name (ni) 186**] is mentally challenged and did not call ems right away so it is reported that pt may have been down for several hours. upon arrival to ed in [**hospital1 1294**] blood sugar was 1400's. rij tl placed and complicated by pneumothorax. right chest tube placed. placed on insulin gtt and admitted to icu. found to have increased liver enzymes, arf and was placed on dialysis. pt had quinton cath in right sc. on [**7-17**] pt was extubated for four hours and then had to be reintubated. u/a found to have [**female first name (un) **], blood cx's negative from osh, cath tip from original fem line shown to have beta strep b from osh. head ct's negative x 2 and abd ct shows small bowel thickened and ascites at osh. ultrasound showed distended gallbladder. pt transferred to [**hospital1 19**] for ? ercp. tbili flat, no indication for ercp at this time. ct removed [**7-25**]. peg/trach/picc line placed [**7-27**] pt. more alert and responsive tonight. sats improving to 100%, at goal for tube feedings. sodium normalizing, repleted potassium alteration in nutrition assessment: abd firm distended, active bt, flexiseal drain mod amt soft stool drk green. tube feeding progressing to goal of 40 cc hr. residuals 30 cc, free water bolus now 250 cc hr. no c/o nausea action: cont. tube feeds at goal 40cc hr, follow residuals closely, cont. flexiseal, response: residuals 30-40 cc hr. now at goal 40 cc hr nutren pulm. site cond. good, abd softer with pos. bt plan: cont. checking residuals freq. tube feeds to cont at goal rate 40 cc hr. , cont. flexiseal line infection (central or arterial) assessment: lab called to note triple lumen grew gr+ cocci in pairs. noted to ho. old line site covered with transparent drsg [**name5 (ptitle) **] [**name5 (ptitle) 1493**] noted, pt afebrile action: monitor wound site. , pt. temps, labs just completed antibiotic coarse. response: no change plan: monitor line site carefully for [**name5 (ptitle) 1493**], respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: good cough effort, thick secretions brwn in color. mod amt. trach site wnl, still some bronchospasm with movement. sats 100% on cpap rr 17-30 when awake. action: pulm toilet, trach cares done, mouth cares, enc. cough and deep breathing. response: improved sats this night. secretions remain thick, plan: wean to trach mask today as able. mobilize follow up on pan culture results as available cardiac dysrhythmia other assessment: pt with irreg irreg hr to 160. no chest pain complaint. bp stable. no further episodes now in sinus to sinus brady 55-70 with some ectopy action: ekg, ho noted. electrolytes drawn response: stable spont converted, no betablockers as adverse reaction to metoprolol and pt. own rate to 60 s with sleep k+ depleted. pt has been autodiuresing this night plan: cont. to monitor, repleted potassium, follow urine output. adjusted free water to 250 cc q 4 hr. ` electrolyte & fluid disorder, other assessment: pt. k= depleted. arrythmias noted no chest pain. sodium normalizing action: total 80 meq kcl divided into 2 doses given this night response: plan: monitor and replete as needed. free water flush 250 cc q 4 hr",1
232,title: respiratory care: pt rec d on 40% t/c with 02 sats ranging between 93-98% pt has # 8 portex trach with cuff deflated. bs are coarse bilaterally and pt is able to expectorate secretions. nebs given as ordered of alb/atr with no adverse reactions. ambu @ hob. no problems [**name (ni) **] and remains stable on t/c with minimal secretions. will continue to follow.,0
233,title: respiratory care: pt rec d on 2 lpm n/c. bs are clear bilaterally with diminished bases. nebs administered as ordered of alb/atr with no adverse reactions.02 sats @ 98%. will continue to follow.,0
234,demographics day of mechanical ventilation: 9 ideal body weight: 47.6 none ideal tidal volume: 190.4 / 285.6 / 380.8 ml/kg airway airway placement data known difficult intubation: unknown ett: position: 20 cm at teeth route: oral type: standard size: 7mm cuff pressure: 21 cmh2o lung sounds rll lung sounds: diminished rul lung sounds: exp wheeze lul lung sounds: exp wheeze lll lung sounds: diminished comments: secretions sputum color / consistency: white / frothy sputum source/amount: suctioned / none comments: sputum sample obtained and sent to lab plan next 24-48 hours: pt presently on psv 12/5+/40%. attempted wean of psv to 10 and pt didn t tolerate. family in room noc. mdi s administered alb/ atr with no adverse reactions. rsbi this am @ 179. no abg s. 02 sats @ 100% plan to wean psv as tolerates. reason for continuing current ventilatory support:,0
235,"82 yr old copd, htn, s/p chole gallstone pancreatitis with ercp drainage c/b hypoxic arrest. tx with therapeutic hypothermia, intubated, found to have a large biliary leak respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: pt remained intubated ,vented,small dose sedation fentanyl 25mics/hr action: pt presently on psv 12/5+/40%. attempted wean of psv to 10 and pt didn t tolerate. family in room noc. mdi s administered alb/ atr with no adverse reactions. rsbi this am 179. no abg s. 02 sats 100% plan to wean psv as tolerates. response: unable to tolerate psv 12.continunig on psv 12. sats 100% plan: further wean as tolerates. cvp dressing changed. bath given and positioned. received lasix 20mg iv x 2 with good effect to maintain neg balance. t drain with minimal drainage. family stayed with pt overnight. completely involved with pt care. t max 99.7. f/u with c/s feed @ 50cc/hr,tolerates well. short running self limiting tachycardia,verapamil dose increased to 80mg",0
236,"lung sounds rll lung sounds: diminished rul lung sounds: exp wheeze lul lung sounds: exp wheeze lll lung sounds: diminished comments: : plan next 24-48 hours: pt ordered for prn nebs, alb/atr administered x 1 this shift with no adverse reactions.",0
237,"subjective: objective: follow up pt visit to address goals of: [**2122-1-13**]. patient seen today for balance training, therapeutic exercise updated medical status: activity clarification i s cg min mod max rolling: supine/ sidelying to sit: max a x 2 t transfer: sit to stand: ambulation: stairs: aerobic activity response: position hr bp rr o[2] sat rpe rest supine 92 121/75 100% cpap activity sit 102 115/70 100% cpap recovery supine 88 123/79 100% cpap total distance walked: minutes: gait: balance: pt required max a x 2 to achieve sitting at eob, she was able to maintain with mod to max a x 1 with r lateral lob. education / communication: pt was seen with ot. pt status discussed with rn other: pt was able to follow approx 50% of commands with max verbal cues in supine, increased to 80% in sitting at eob. pt was more lethargic today, had just received phenobarb no observed r scalene spasms pulm strong cough suctioned for mod amounts of secretions assessment: 41 yo f admitted [**12-30**] c meningoencephalitis continues to be intubated and on versed and phenobarb, she is still able to actively participate with pt even on high levels of sedatives and did not so any adverse reactions to sitting at eob, ie no witnessed sz activity. pt will benefit from continuing to increase activity for skin integrity, strength, and pulmonary status. anticipated discharge: rehab plan: cont to progress activity as tolerated",1
238,demographics day of mechanical ventilation: 0 ideal body weight: 67.1 none ideal tidal volume: 268.4 / 402.6 / 536.8 ml/kg airway tracheostomy tube: type: standard manufacturer: shiley size: 7.0mm lung sounds rll lung sounds: diminished rul lung sounds: rhonchi lul lung sounds: rhonchi lll lung sounds: diminished comments: secretions sputum color / consistency: yellow / thick sputum source/amount: suctioned / moderate comments: ventilation assessment level of breathing assistance: unassisted spontaneous breathing visual assessment of breathing pattern: accessory muscle use plan next 24-48 hours: mdi's administered atr with no adverse reactions. trach care performed/ inner cannula cleaned and replaced reason for continuing current ventilatory support:,0
239,"clinician: resident i was asked by mr. [**known lastname 4736**]' nurse to clarify his acetylcysteine dosing. based on a sheet handed to me by hepatology, i ordered 10,000 mg per hour of acetylcysteine. pharmacy sent up a total of 3 bags of acetylcysteine that were dosed in the following way: he continued on an infusion of nac on which he had been started at [**hospital1 609**] until 7 pm when our medication was ready. the infusion was running at 63 cc/hr w/ unknown concentration. bag 1) started at approximately 7 pm and contained 10,000 mg in 500 cc ns. this was run at 63 cc/hr. bag 2) started at 2 am contained 10,000 mg in 500 cc ns. this was run at 63 cc/hr and ended at 12:30 pm. bag 3 was sent up but never given. it contained 10,000 mg in 250 cc ns. thus, instead of receiving the usual dosing of 20,000 mg in 32 hours, he received 20,000 mg in 17-20 hours. pharmacy was called and helped to clarify the actual dosing. the toxicology team was called to determine if this could have any potential adverse reactions for the patient. they said that the most common reaction to acetylcysteine is an aniphylactoid reaction that usually happens in the first several minutes. they believe that the likelihood of adverse reaction is very low. they have called poison control to confirm this and the recommendation is that we continue to monitor him carefully. in fact, there are some high-dose protocols that approximate this dosing scheme. dr. [**last name (stitle) 385**] was notified and she and i assessed mr. [**known lastname 4736**] and let him know that he may have received his medication a little faster than intended and that we were looking into this. mrs. [**known lastname 4736**] states that his breathing is tight and that he feels very hot from his fever. no n/v/abdominal pain. on physical exam: 102, 138, 149/77, 44, 93% on 3l. cv tachycardic. lungs w/ occasional inspiratory wheeze. abdomen soft, nt, nd, nabs no rash noted a/p mr. [**known lastname 4736**] is a 23 m transferred from [**hospital1 609**] on nad for tylenol and benadryl overdose, now found to have received a faster infusion rate than intended. he is currently tachycardic and mildly tachypneic but we believe that this is due to his known rll aspiration pna. nonetheless, we will follow him very closely for adverse reactions and take steps to clarify this process in the future. total time spent: 45 minutes",1
240,"chief complaint: 24 hour events: invasive ventilation - stop [**2124-2-4**] 03:30 pm patient made cmo by family. extubated. family at bedside allergies: codeine nausea/vomiting ambien (oral) (zolpidem tartrate) unknown; last dose of antibiotics: vancomycin - [**2124-2-2**] 09:39 pm piperacillin/tazobactam (zosyn) - [**2124-2-3**] 12:41 am infusions: fentanyl - 175 mcg/hour other icu medications: pantoprazole (protonix) - [**2124-2-4**] 08:32 am midazolam (versed) - [**2124-2-4**] 03:30 pm fentanyl - [**2124-2-4**] 06:17 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2124-2-5**] 05:58 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.5 c (97.7 tcurrent: 35.9 c (96.7 hr: 69 (67 - 78) bpm bp: 57/28(34) {51/23(30) - 112/43,100(85)} mmhg rr: 10 (0 - 21) insp/min spo2: 94% heart rhythm: af (atrial fibrillation) cvp: 11 (10 - 21)mmhg total in: 1,947 ml 164 ml po: tf: ivf: 1,947 ml 164 ml blood products: total out: 445 ml 25 ml urine: 445 ml 25 ml ng: stool: drains: balance: 1,502 ml 139 ml respiratory support o2 delivery device: nasal cannula ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml rr (set): 18 peep: 5 cmh2o fio2: 40% pip: 22 cmh2o plateau: 14 cmh2o spo2: 94% abg: //// ve: 9.5 l/min physical examination general: pt laying in bed, appears comfortable, agonally breathing heent: op clear. minimal secretions cv: brady. irreg. [**4-15**] syst murmur. resp: coarse bs abd: soft. nt. +bs ext: 2+ edema ue/le labs / radiology 110 k/ul 10.1 g/dl 140 mg/dl 1.1 mg/dl 23 meq/l 3.9 meq/l 16 mg/dl 114 meq/l 144 meq/l 29.0 % 7.8 k/ul [image002.jpg] [**2124-2-1**] 03:52 pm [**2124-2-1**] 05:20 pm [**2124-2-1**] 08:39 pm [**2124-2-2**] 04:07 am [**2124-2-2**] 04:46 am [**2124-2-2**] 06:43 am [**2124-2-3**] 01:58 am [**2124-2-3**] 02:15 am [**2124-2-3**] 05:57 pm [**2124-2-4**] 03:24 am wbc 7.1 4.6 5.2 7.8 hct 27.6 26.7 27.1 29.0 plt 131 110 96 110 cr 1.4 1.4 1.0 1.0 1.1 tco2 20 21 23 23 24 glucose 156 175 128 138 140 other labs: pt / ptt / inr:23.5/58.0/2.3, ck / ckmb / troponin-t:468/12/0.06, alt / ast:13/34, alk phos / t bili:32/4.4, differential-neuts:78.8 %, lymph:10.7 %, mono:7.8 %, eos:2.5 %, lactic acid:1.8 mmol/l, albumin:3.7 g/dl, ldh:250 iu/l, ca++:8.7 mg/dl, mg++:1.7 mg/dl, po4:2.3 mg/dl assessment and plan 71 gentleman with alcoholic cirrhosis c/b portal htn, refractory ascites admitted for tips revision s/p revision and portal vein thrombolysis [**1-28**] with worsening encephalopathy, ms changes, hypoxia and hypotension now cmo s/p extubation. . # hypoxemic respiratory failure/ /hypotension: made cmo yesterday. extubated. off pressors with minimal uop (0-5cc per hour). appears comfortable. family at bedside. . # mental status changes: timing coincides with tips revision. likely multifactorial secondary to post op delirium, encephalopathy from patent tips and lack of lactulose, underlying cognitive dysfunction, and possible infection. head ct negative for bleed but his ventricles were enlarged with ? communicating hydrocephalus. per discussion with neurology, hydrocephalus unlikely cause of ms changes and is likely chronic. head ct did not show any acute signs of hemorrhage which was concern while on anticoagulation. also concern for sepsis with low uop, borderline low bps. on vanc, zosyn now for asp pna and empiric sbp treatment but will stop since no cx data, no fevers and may be causing adverse reaction with rash. para negative for sbp. ua negative. bld cx ngtd. at this point the only issue not addressed is lactulose for encephalopathy, which is impossible without ngt placement. family meeting will take place today to discuss goals of care and whether ngt is within their wishes. patient appears comfortable on exam, on fentanyl drip. . # tips revision: had revision [**1-28**]. thrombolysis, angioplasty done with gradient of 6 after procedure was finished. per ir, no need for heparin. briefly on lovenox but discontinued since pt at risk for bleeding. ruq us demonstrates flow but could not assess gradient since agitated. - will not undergo reversal given family s wishes to avoid invasive procedures . # portal vein thrombosis: s/p thrombolysis and angioplasty. # pacemaker malfunction/ecg changes: pacemaker not functioning properly per ep secondary to microdislodgement of rv lead per ep. has a history of high grade avb. no revision at this time. - off invasive monitoring # anemia: transfused 1 unit on this admission, hct relatively stable since around baseline and bumped appropriately to i unit. no egd since [**2119**]. theoretically, if tips patent would not need prophylaxis for varices but tips gradient unknown. if hct decreases, will consider checking [**hospital1 7**] hcts -stable, no longer checking labs . # acute renal failure: baseline cr~1. cr stable to improved, 1 today. to maintain minimal uop requires bolus ns and continued pressors. - holding lasix and spironolactone - pressors d/c -minimal uop, not following labs . # le edema: pt had lle edema greater than r concerning for dvt. lle us negative for dvt but limited study due to agitation. lenis negative for dvt . # alcoholic cirrhosis: inactive on transplant list. - hold lasix and spironolactone given arf - appreciate hepatology recs . # thrombocytopenia: plt count stabilized, c/w prior baseline 80s-100s . # dm2: off hiss, cmo. . # fen/gi unable to feed since cannot place ngt/ogt per family request , replete lytes prn . # ppx - cmo . # access - piv , rij cvl and left radial a line placed . # code dnr/dni (confirmed with pt). pt's daughter [**name (ni) 4522**] [**numeric identifier 4523**]. cell [**telephone/fax (1) 4524**] . # dispo icu; plan pending family discussion comfort care (cmo, comfort measures) rash renal failure, acute (acute renal failure, arf) impaired skin integrity .h/o diabetes mellitus (dm), type ii hypotension (not shock) airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) altered mental status (not delirium) alteration in nutrition .h/o alcohol withdrawal (including delirium tremens, dts, seizures) icu care nutrition: glycemic control: lines: multi lumen - [**2124-2-1**] 12:49 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: comfort measures only disposition: ------ protected section ------ micu attending addendum i was physically present with the icu team for the key portions of the services provided. i agree with the note above, including the assessment and plan. i would emphasize and add the following points: 71m etoh cirrhosis, tips [**1-28**] for refractory ascites, progressive encephalopathy, hypoxemia following attempted ngt placement. per family meeting yesterday, pt is now cmo. patient is unresponsive and per family comfortable after changing from fentanyl to morphine. hr remains in 70 s with bp measured in 40 s systolic. reassurance and comfort provided. no new therapies. remainder of plan as outlined above. patient is critically ill total time: 30 min ------ protected section addendum entered by:[**name (ni) 20**] [**last name (namepattern1) 885**], md on:[**2124-2-5**] 16:00 ------",1
241,"chief complaint: 24 hour events: invasive ventilation - stop [**2124-2-4**] 03:30 pm patient made cmo by family. extubated. family at bedside allergies: codeine nausea/vomiting ambien (oral) (zolpidem tartrate) unknown; last dose of antibiotics: vancomycin - [**2124-2-2**] 09:39 pm piperacillin/tazobactam (zosyn) - [**2124-2-3**] 12:41 am infusions: fentanyl - 175 mcg/hour other icu medications: pantoprazole (protonix) - [**2124-2-4**] 08:32 am midazolam (versed) - [**2124-2-4**] 03:30 pm fentanyl - [**2124-2-4**] 06:17 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2124-2-5**] 05:58 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.5 c (97.7 tcurrent: 35.9 c (96.7 hr: 69 (67 - 78) bpm bp: 57/28(34) {51/23(30) - 112/43,100(85)} mmhg rr: 10 (0 - 21) insp/min spo2: 94% heart rhythm: af (atrial fibrillation) cvp: 11 (10 - 21)mmhg total in: 1,947 ml 164 ml po: tf: ivf: 1,947 ml 164 ml blood products: total out: 445 ml 25 ml urine: 445 ml 25 ml ng: stool: drains: balance: 1,502 ml 139 ml respiratory support o2 delivery device: nasal cannula ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml rr (set): 18 peep: 5 cmh2o fio2: 40% pip: 22 cmh2o plateau: 14 cmh2o spo2: 94% abg: //// ve: 9.5 l/min physical examination general: pt laying in bed, appears comfortable, agonally breathing heent: op clear. minimal secretions cv: brady. irreg. [**4-15**] syst murmur. resp: coarse bs abd: soft. nt. +bs ext: 2+ edema ue/le labs / radiology 110 k/ul 10.1 g/dl 140 mg/dl 1.1 mg/dl 23 meq/l 3.9 meq/l 16 mg/dl 114 meq/l 144 meq/l 29.0 % 7.8 k/ul [image002.jpg] [**2124-2-1**] 03:52 pm [**2124-2-1**] 05:20 pm [**2124-2-1**] 08:39 pm [**2124-2-2**] 04:07 am [**2124-2-2**] 04:46 am [**2124-2-2**] 06:43 am [**2124-2-3**] 01:58 am [**2124-2-3**] 02:15 am [**2124-2-3**] 05:57 pm [**2124-2-4**] 03:24 am wbc 7.1 4.6 5.2 7.8 hct 27.6 26.7 27.1 29.0 plt 131 110 96 110 cr 1.4 1.4 1.0 1.0 1.1 tco2 20 21 23 23 24 glucose 156 175 128 138 140 other labs: pt / ptt / inr:23.5/58.0/2.3, ck / ckmb / troponin-t:468/12/0.06, alt / ast:13/34, alk phos / t bili:32/4.4, differential-neuts:78.8 %, lymph:10.7 %, mono:7.8 %, eos:2.5 %, lactic acid:1.8 mmol/l, albumin:3.7 g/dl, ldh:250 iu/l, ca++:8.7 mg/dl, mg++:1.7 mg/dl, po4:2.3 mg/dl assessment and plan 71 gentleman with alcoholic cirrhosis c/b portal htn, refractory ascites admitted for tips revision s/p revision and portal vein thrombolysis [**1-28**] with worsening encephalopathy, ms changes, hypoxia and hypotension now cmo s/p extubation. . # hypoxemic respiratory failure/ /hypotension: made cmo yesterday. extubated. off pressors with minimal uop (0-5cc per hour). appears comfortable. family at bedside. . # mental status changes: timing coincides with tips revision. likely multifactorial secondary to post op delirium, encephalopathy from patent tips and lack of lactulose, underlying cognitive dysfunction, and possible infection. head ct negative for bleed but his ventricles were enlarged with ? communicating hydrocephalus. per discussion with neurology, hydrocephalus unlikely cause of ms changes and is likely chronic. head ct did not show any acute signs of hemorrhage which was concern while on anticoagulation. also concern for sepsis with low uop, borderline low bps. on vanc, zosyn now for asp pna and empiric sbp treatment but will stop since no cx data, no fevers and may be causing adverse reaction with rash. para negative for sbp. ua negative. bld cx ngtd. at this point the only issue not addressed is lactulose for encephalopathy, which is impossible without ngt placement. family meeting will take place today to discuss goals of care and whether ngt is within their wishes. patient appears comfortable on exam, on fentanyl drip. . # tips revision: had revision [**1-28**]. thrombolysis, angioplasty done with gradient of 6 after procedure was finished. per ir, no need for heparin. briefly on lovenox but discontinued since pt at risk for bleeding. ruq us demonstrates flow but could not assess gradient since agitated. - will not undergo reversal given family s wishes to avoid invasive procedures . # portal vein thrombosis: s/p thrombolysis and angioplasty. # pacemaker malfunction/ecg changes: pacemaker not functioning properly per ep secondary to microdislodgement of rv lead per ep. has a history of high grade avb. no revision at this time. - off invasive monitoring # anemia: transfused 1 unit on this admission, hct relatively stable since around baseline and bumped appropriately to i unit. no egd since [**2119**]. theoretically, if tips patent would not need prophylaxis for varices but tips gradient unknown. if hct decreases, will consider checking [**hospital1 7**] hcts -stable, no longer checking labs . # acute renal failure: baseline cr~1. cr stable to improved, 1 today. to maintain minimal uop requires bolus ns and continued pressors. - holding lasix and spironolactone - pressors d/c -minimal uop, not following labs . # le edema: pt had lle edema greater than r concerning for dvt. lle us negative for dvt but limited study due to agitation. lenis negative for dvt . # alcoholic cirrhosis: inactive on transplant list. - hold lasix and spironolactone given arf - appreciate hepatology recs . # thrombocytopenia: plt count stabilized, c/w prior baseline 80s-100s . # dm2: off hiss, cmo. . # fen/gi unable to feed since cannot place ngt/ogt per family request , replete lytes prn . # ppx - cmo . # access - piv , rij cvl and left radial a line placed . # code dnr/dni (confirmed with pt). pt's daughter [**name (ni) 4522**] [**numeric identifier 4523**]. cell [**telephone/fax (1) 4524**] . # dispo icu; plan pending family discussion comfort care (cmo, comfort measures) rash renal failure, acute (acute renal failure, arf) impaired skin integrity .h/o diabetes mellitus (dm), type ii hypotension (not shock) airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) altered mental status (not delirium) alteration in nutrition .h/o alcohol withdrawal (including delirium tremens, dts, seizures) icu care nutrition: glycemic control: lines: multi lumen - [**2124-2-1**] 12:49 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: comfort measures only disposition:",1
242,"chief complaint: 24 hour events: arterial line - stop [**2124-2-4**] 12:00 am made dnr yesterday. no more invasive procedures. family considering cmo. allergies: codeine nausea/vomiting ambien (oral) (zolpidem tartrate) unknown; last dose of antibiotics: vancomycin - [**2124-2-2**] 09:39 pm piperacillin/tazobactam (zosyn) - [**2124-2-3**] 12:41 am infusions: midazolam (versed) - 3 mg/hour fentanyl - 100 mcg/hour norepinephrine - 0.24 mcg/kg/min other icu medications: pantoprazole (protonix) - [**2124-2-3**] 08:04 pm midazolam (versed) - [**2124-2-4**] 12:06 am fentanyl - [**2124-2-4**] 12:07 am heparin sodium (prophylaxis) - [**2124-2-4**] 04:27 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2124-2-4**] 05:42 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.9 c (98.5 tcurrent: 35.8 c (96.5 hr: 70 (65 - 78) bpm bp: 113/65(77) {62/42(47) - 125/74(83)} mmhg rr: 17 (16 - 22) insp/min spo2: 98% heart rhythm: af (atrial fibrillation) cvp: 12 (8 - 17)mmhg total in: 4,163 ml 420 ml po: tf: ivf: 3,963 ml 420 ml blood products: 200 ml total out: 765 ml 170 ml urine: 765 ml 170 ml ng: stool: drains: balance: 3,398 ml 250 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml rr (set): 18 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi deferred: neuromusc block pip: 19 cmh2o plateau: 14 cmh2o compliance: 55.6 cmh2o/ml spo2: 98% abg: ///23/ ve: 8.9 l/min physical examination general: intubated, sedated, opens eyes to sternal rub, not responsive to voice or following commands heent: perrl, pinpoint, anicteric heart: rrr 2/6 systolic murmur best heard at lusb radiating to carotids lungs: coarse bs, diminished in anterior lung fields. abd: +bs hypoactive, nt, mildy distended, soft ext: trace edema b/l with chronic venous stasis changes (l>r), wwp, ue edema bl l>r skin: multiple echymosis. diffuse maculopapular rash over abdomen (stable from yesterday) labs / radiology 110 k/ul 10.1 g/dl 140 mg/dl 1.1 mg/dl 23 meq/l 3.9 meq/l 16 mg/dl 114 meq/l 144 meq/l 29.0 % 7.8 k/ul [image002.jpg] [**2124-2-1**] 03:52 pm [**2124-2-1**] 05:20 pm [**2124-2-1**] 08:39 pm [**2124-2-2**] 04:07 am [**2124-2-2**] 04:46 am [**2124-2-2**] 06:43 am [**2124-2-3**] 01:58 am [**2124-2-3**] 02:15 am [**2124-2-3**] 05:57 pm [**2124-2-4**] 03:24 am wbc 7.1 4.6 5.2 7.8 hct 27.6 26.7 27.1 29.0 plt 131 110 96 110 cr 1.4 1.4 1.0 1.0 1.1 tco2 20 21 23 23 24 glucose 156 175 128 138 140 other labs: pt / ptt / inr:23.5/58.0/2.3, ck / ckmb / troponin-t:468/12/0.06, alt / ast:13/34, alk phos / t bili:32/4.4, differential-neuts:78.8 %, lymph:10.7 %, mono:7.8 %, eos:2.5 %, lactic acid:1.8 mmol/l, albumin:3.7 g/dl, ldh:250 iu/l, ca++:8.7 mg/dl, mg++:1.7 mg/dl, po4:2.3 mg/dl assessment and plan 71 gentleman with alcoholic cirrhosis c/b portal htn, refractory ascites s/p tips [**2119**] found to have occluded tips by u/s in [**12-18**] now s/p tips revision [**2124-1-28**] and portal vein thrombolysis transferred with hypoxia and altered mental status now intubated with persistent hypotension and pressor requirement. . # hypoxemic respiratory failure: hypoxia most likely secondary to aspiration given witnessed aspiration event, decreased o2 sats, new tachypnea, infiltrates on cxr. hap less likely since no fever or elevated wbc. cta negative for pe. other less likely etiologies include hps. finally, his respiratory support is in question at this point pending family meeting to discuss what their goals of care are, and whether extubation is within their wishes. - will d/c vanc/zosyn for hap coverage since no clear indication and may be causing drug reaction - would continue to try and switch to ps and wean as tolerated, not to plan on extubating but to assess pulmonary status - abgs as needed . # mental status changes: timing coincides with tips revision. likely multifactorial secondary to post op delirium, encephalopathy from patent tips and lack of lactulose, underlying cognitive dysfunction, and possible infection. head ct negative for bleed but his ventricles were enlarged with ? communicating hydrocephalus. per discussion with neurology, hydrocephalus unlikely cause of ms changes and is likely chronic. head ct did not show any acute signs of hemorrhage which was concern while on anticoagulation. also concern for sepsis with low uop, borderline low bps. on vanc, zosyn now for asp pna and empiric sbp treatment but will stop since no cx data, no fevers and may be causing adverse reaction with rash. para negative for sbp. ua negative. bld cx ngtd. at this point the only issue not addressed is lactulose for encephalopathy, which is impossible without ngt placement. family meeting will take place today to discuss goals of care and whether ngt is within their wishes. - unable to treat encephalopathy without ngt - on fentanyl and versed for sedation, will titrate to avoid agitation and oversedation - follow up pending cultures - discuss w/family if egd to place ngt is ok . # hypotension: hypotension likely multifactorial secondary to liver disease, ventilator and peep, rv impairment, infection/sepsis. he continues to require pressors and has minimal uop (20-30cc/hr). will add on a second pressor today and continue to monitor. there is question whether a line is [**location (un) **] accurately. - continue levophed, add vasopressin - bolus ns - follow uop - ? [**first name8 (namepattern2) 1619**] [**location (un) **] may be positional, correlate with nbp . # tips revision: had revision [**1-28**]. thrombolysis, angioplasty done with gradient of 6 after procedure was finished. per ir, no need for heparin. briefly on lovenox but discontinued since pt at risk for bleeding. ruq us demonstrates flow but could not assess gradient since agitated. - f/u further ir recs - will likely not undergo reversal given family s wishes to avoid invasive procedures . # portal vein thrombosis: s/p thrombolysis and angioplasty. - no anti-coag for now, has inr>2.0 # pacemaker malfunction/ecg changes: pacemaker not functioning properly per ep secondary to microdislodgement of rv lead per ep. has a history of high grade avb. no revision at this time. - appreciate ep recs - no nodal agents - telemetry # anemia: transfused 1 unit on this admission, hct relatively stable since around baseline and bumped appropriately to i unit. no egd since [**2119**]. theoretically, if tips patent would not need prophylaxis for varices but tips gradient unknown. if hct decreases, will consider checking [**hospital1 7**] hcts -stable . # acute renal failure: baseline cr~1. cr stable to improved, 1 today. to maintain minimal uop requires bolus ns and continued pressors. will monitor at this time and add vasopressing. - holding lasix and spironolactone - ns boluses prn low uop - maintain map 60s to maintaijn perfusion pressure - [**hospital1 7**] albumin . # gout: on colchicine . # le edema: pt had lle edema greater than r concerning for dvt. lle us negative for dvt but limited study due to agitation. lenis negative for dvt . # alcoholic cirrhosis: inactive on transplant list. - hold lasix and spironolactone given arf - appreciate hepatology recs . # thrombocytopenia: plt count stabilized, c/w prior baseline 80s-100s . # dm2: maintain glycemic control with hiss. . # fen/gi unable to feed since cannot place ngt/ogt per family request , replete lytes prn . # ppx - sub q heparin, ppi . # access - piv , rij cvl and left radial a line placed . # code dnr/dni (confirmed with pt). pt's daughter [**name (ni) 4522**] [**numeric identifier 4523**]. cell [**telephone/fax (1) 4524**] . # dispo icu; plan pending family discussion hypotension (not shock) airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) altered mental status (not delirium) alteration in nutrition .h/o alcohol withdrawal (including delirium tremens, dts, seizures) icu care nutrition: glycemic control: lines: 18 gauge - [**2124-2-1**] 11:00 am multi lumen - [**2124-2-1**] 12:49 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: dnr / dni disposition: ------ protected section ------ micu attending addendum i saw and examined the patient, and was physically present with the icu team for the key portions of the services provided. i agree with the note above, including the assessment and plan. i would emphasize and add the following points: 71m etoh cirrhosis, tips [**1-28**] for refractory ascites, progressive encephalopathy, hypoxemia following attempted ngt placement. remains intubated, family refuses further procedures pending meeting today at 1pm. exam notable for tm 98.0 bp 85/40 hr 68af (no capture on pacer spikes) rr 21 with sat 95 on vac 500x18 8 0.4. unresponsive / sedated. diffuse ronchi, irreg s1s2 2/6sm. distended, abdomen, +bs. 3+ edema, rash over trunk. labs notable for wbc 7k, hct 29, k+ 3.9, cr 1.1, na 144. agree with plan to treat aspiration pneumonitis c/b respiratory failure with sedation and vent support, no clear evidence for pneumonia so will hold abx, especially given new drug rash. will lighten sedation and add vpa if needed for bp support. will manage encephalopathy with endoscopic ngt placement, lactulose, rifaximin if family agrees. anemia and cri are stable. care and overall prognosis to be reviewed with son and daughter today at 1pm. based on prior discussion [**2-2**], patient would not want chronic support, but will continue with current level of care in an effort to reverse encephalopathy. mr. [**known lastname **] is dnr. remainder of plan as outlined above. patient is critically ill total time: 50 min ------ protected section addendum entered by:[**name (ni) 453**] [**last name (namepattern1) 775**], md on:[**2124-2-4**] 14:21 ------",1
243,"chief complaint: 24 hour events: arterial line - stop [**2124-2-4**] 12:00 am made dnr yesterday. no more invasive procedures. family considering cmo. allergies: codeine nausea/vomiting ambien (oral) (zolpidem tartrate) unknown; last dose of antibiotics: vancomycin - [**2124-2-2**] 09:39 pm piperacillin/tazobactam (zosyn) - [**2124-2-3**] 12:41 am infusions: midazolam (versed) - 3 mg/hour fentanyl - 100 mcg/hour norepinephrine - 0.24 mcg/kg/min other icu medications: pantoprazole (protonix) - [**2124-2-3**] 08:04 pm midazolam (versed) - [**2124-2-4**] 12:06 am fentanyl - [**2124-2-4**] 12:07 am heparin sodium (prophylaxis) - [**2124-2-4**] 04:27 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2124-2-4**] 05:42 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.9 c (98.5 tcurrent: 35.8 c (96.5 hr: 70 (65 - 78) bpm bp: 113/65(77) {62/42(47) - 125/74(83)} mmhg rr: 17 (16 - 22) insp/min spo2: 98% heart rhythm: af (atrial fibrillation) cvp: 12 (8 - 17)mmhg total in: 4,163 ml 420 ml po: tf: ivf: 3,963 ml 420 ml blood products: 200 ml total out: 765 ml 170 ml urine: 765 ml 170 ml ng: stool: drains: balance: 3,398 ml 250 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml rr (set): 18 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi deferred: neuromusc block pip: 19 cmh2o plateau: 14 cmh2o compliance: 55.6 cmh2o/ml spo2: 98% abg: ///23/ ve: 8.9 l/min physical examination general: intubated, sedated, opens eyes to sternal rub, not responsive to voice or following commands heent: perrl, pinpoint, anicteric heart: rrr 2/6 systolic murmur best heard at lusb radiating to carotids lungs: coarse bs, diminished in anterior lung fields. abd: +bs hypoactive, nt, mildy distended, soft ext: trace edema b/l with chronic venous stasis changes (l>r), wwp, ue edema bl l>r skin: multiple echymosis. diffuse maculopapular rash over abdomen (stable from yesterday) labs / radiology 110 k/ul 10.1 g/dl 140 mg/dl 1.1 mg/dl 23 meq/l 3.9 meq/l 16 mg/dl 114 meq/l 144 meq/l 29.0 % 7.8 k/ul [image002.jpg] [**2124-2-1**] 03:52 pm [**2124-2-1**] 05:20 pm [**2124-2-1**] 08:39 pm [**2124-2-2**] 04:07 am [**2124-2-2**] 04:46 am [**2124-2-2**] 06:43 am [**2124-2-3**] 01:58 am [**2124-2-3**] 02:15 am [**2124-2-3**] 05:57 pm [**2124-2-4**] 03:24 am wbc 7.1 4.6 5.2 7.8 hct 27.6 26.7 27.1 29.0 plt 131 110 96 110 cr 1.4 1.4 1.0 1.0 1.1 tco2 20 21 23 23 24 glucose 156 175 128 138 140 other labs: pt / ptt / inr:23.5/58.0/2.3, ck / ckmb / troponin-t:468/12/0.06, alt / ast:13/34, alk phos / t bili:32/4.4, differential-neuts:78.8 %, lymph:10.7 %, mono:7.8 %, eos:2.5 %, lactic acid:1.8 mmol/l, albumin:3.7 g/dl, ldh:250 iu/l, ca++:8.7 mg/dl, mg++:1.7 mg/dl, po4:2.3 mg/dl assessment and plan 71 gentleman with alcoholic cirrhosis c/b portal htn, refractory ascites s/p tips [**2119**] found to have occluded tips by u/s in [**12-18**] now s/p tips revision [**2124-1-28**] and portal vein thrombolysis transferred with hypoxia and altered mental status now intubated with persistent hypotension and pressor requirement. . # hypoxemic respiratory failure: hypoxia most likely secondary to aspiration given witnessed aspiration event, decreased o2 sats, new tachypnea, infiltrates on cxr. hap less likely since no fever or elevated wbc. cta negative for pe. other less likely etiologies include hps. finally, his respiratory support is in question at this point pending family meeting to discuss what their goals of care are, and whether extubation is within their wishes. - will d/c vanc/zosyn for hap coverage since no clear indication and may be causing drug reaction - would continue to try and switch to ps and wean as tolerated, not to plan on extubating but to assess pulmonary status - abgs as needed . # mental status changes: timing coincides with tips revision. likely multifactorial secondary to post op delirium, encephalopathy from patent tips and lack of lactulose, underlying cognitive dysfunction, and possible infection. head ct negative for bleed but his ventricles were enlarged with ? communicating hydrocephalus. per discussion with neurology, hydrocephalus unlikely cause of ms changes and is likely chronic. head ct did not show any acute signs of hemorrhage which was concern while on anticoagulation. also concern for sepsis with low uop, borderline low bps. on vanc, zosyn now for asp pna and empiric sbp treatment but will stop since no cx data, no fevers and may be causing adverse reaction with rash. para negative for sbp. ua negative. bld cx ngtd. at this point the only issue not addressed is lactulose for encephalopathy, which is impossible without ngt placement. family meeting will take place today to discuss goals of care and whether ngt is within their wishes. - unable to treat encephalopathy without ngt - on fentanyl and versed for sedation, will titrate to avoid agitation and oversedation - follow up blood cx, urine cx, ascetic cx, obtain sputum cx and restart abx if indicated . # hypotension: hypotension likely multifactorial secondary to liver disease, ventilator and peep, rv impairment, infection/sepsis. - continue pressors (currently on levophed) titrate to lower map 60s - would not add second pressor without family discussion regarding management, just bolus for now, accept lower bps - follow uop # tips revision: had revision [**1-28**]. thrombolysis, angioplasty done with gradient of 6 after procedure was finished. per ir, no need for heparin. briefly on lovenox but discontinued since pt at risk for bleeding. ruq us demonstrates flow but could not assess gradient since agitated. - f/u further ir recs - consider reversing tips due to gross encephalopathy but pt s family does not want further invasive procedures . # portal vein thrombosis: s/p thrombolysis and angioplasty. - no anti-coag for now, has inr>2.0 # pacemaker malfunction/ecg changes: pacemaker not functioning properly per ep secondary to microdislodgement of rv lead per ep. has a history of high grade avb. if recovers, will need lead revision. - appreciate ep recs - no nodal agents - telemetry # anemia: transfused 1 unit on this admission, hct relatively stable since around baseline and bumped appropriately to i unit. no egd since [**2119**]. theoretically, if tips patent would not need prophylaxis for varices but tips gradient unknown. if hct decreases, will consider checking [**hospital1 7**] hcts . # acute renal failure: baseline cr~1. cr stable to improved, 1 today. has had good uop last 24 hours, requiring boluses x 2 for low uop and bp but seems to respond well to this. - holding lasix and spironolactone - ns boluses prn low uop - maintain map 60s to maintaijn perfusion pressure - [**hospital1 7**] albumin . # gout: on colchicine . # le edema: pt had lle edema greater than r concerning for dvt. lle us negative for dvt but limited study due to agitation. lenis negative for dvt . # alcoholic cirrhosis: inactive on transplant list. - hold lasix and spironolactone given arf - appreciate hepatology recs . # thrombocytopenia: plt count stabilized, c/w prior baseline 80s-100s . # dm2: maintain glycemic control with hiss. . # fen/gi unable to feed since cannot place ngt/ogt per pt request , replete lytes prn . # ppx - sub q heparin, ppi . # access - piv , rij cvl and left radial a line placed . # code - full (confirmed with pt). pt's daughter [**name (ni) 4522**] [**numeric identifier 4523**]. cell [**telephone/fax (1) 4524**] . # dispo - pending improvement in mental status hypotension (not shock) airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) altered mental status (not delirium) alteration in nutrition .h/o alcohol withdrawal (including delirium tremens, dts, seizures) icu care nutrition: glycemic control: lines: 18 gauge - [**2124-2-1**] 11:00 am multi lumen - [**2124-2-1**] 12:49 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: dnr / dni disposition:",1
244,"chief complaint: 24 hour events: arterial line - stop [**2124-2-4**] 12:00 am made dnr yesterday. no more invasive procedures. family considering cmo. allergies: codeine nausea/vomiting ambien (oral) (zolpidem tartrate) unknown; last dose of antibiotics: vancomycin - [**2124-2-2**] 09:39 pm piperacillin/tazobactam (zosyn) - [**2124-2-3**] 12:41 am infusions: midazolam (versed) - 3 mg/hour fentanyl - 100 mcg/hour norepinephrine - 0.24 mcg/kg/min other icu medications: pantoprazole (protonix) - [**2124-2-3**] 08:04 pm midazolam (versed) - [**2124-2-4**] 12:06 am fentanyl - [**2124-2-4**] 12:07 am heparin sodium (prophylaxis) - [**2124-2-4**] 04:27 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2124-2-4**] 05:42 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.9 c (98.5 tcurrent: 35.8 c (96.5 hr: 70 (65 - 78) bpm bp: 113/65(77) {62/42(47) - 125/74(83)} mmhg rr: 17 (16 - 22) insp/min spo2: 98% heart rhythm: af (atrial fibrillation) cvp: 12 (8 - 17)mmhg total in: 4,163 ml 420 ml po: tf: ivf: 3,963 ml 420 ml blood products: 200 ml total out: 765 ml 170 ml urine: 765 ml 170 ml ng: stool: drains: balance: 3,398 ml 250 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml rr (set): 18 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi deferred: neuromusc block pip: 19 cmh2o plateau: 14 cmh2o compliance: 55.6 cmh2o/ml spo2: 98% abg: ///23/ ve: 8.9 l/min physical examination general: intubated, sedated, opens eyes to sternal rub, not responsive to voice or following commands heent: perrl, pinpoint, anicteric heart: rrr 2/6 systolic murmur best heard at lusb radiating to carotids lungs: coarse bs, diminished in anterior lung fields. abd: +bs hypoactive, nt, mildy distended, soft ext: trace edema b/l with chronic venous stasis changes (l>r), wwp, ue edema bl l>r skin: multiple echymosis. diffuse maculopapular rash over abdomen (stable from yesterday) labs / radiology 110 k/ul 10.1 g/dl 140 mg/dl 1.1 mg/dl 23 meq/l 3.9 meq/l 16 mg/dl 114 meq/l 144 meq/l 29.0 % 7.8 k/ul [image002.jpg] [**2124-2-1**] 03:52 pm [**2124-2-1**] 05:20 pm [**2124-2-1**] 08:39 pm [**2124-2-2**] 04:07 am [**2124-2-2**] 04:46 am [**2124-2-2**] 06:43 am [**2124-2-3**] 01:58 am [**2124-2-3**] 02:15 am [**2124-2-3**] 05:57 pm [**2124-2-4**] 03:24 am wbc 7.1 4.6 5.2 7.8 hct 27.6 26.7 27.1 29.0 plt 131 110 96 110 cr 1.4 1.4 1.0 1.0 1.1 tco2 20 21 23 23 24 glucose 156 175 128 138 140 other labs: pt / ptt / inr:23.5/58.0/2.3, ck / ckmb / troponin-t:468/12/0.06, alt / ast:13/34, alk phos / t bili:32/4.4, differential-neuts:78.8 %, lymph:10.7 %, mono:7.8 %, eos:2.5 %, lactic acid:1.8 mmol/l, albumin:3.7 g/dl, ldh:250 iu/l, ca++:8.7 mg/dl, mg++:1.7 mg/dl, po4:2.3 mg/dl assessment and plan 71 gentleman with alcoholic cirrhosis c/b portal htn, refractory ascites s/p tips [**2119**] found to have occluded tips by u/s in [**12-18**] now s/p tips revision [**2124-1-28**] and portal vein thrombolysis transferred with hypoxia and altered mental status now intubated with persistent hypotension and pressor requirement. . # hypoxemic respiratory failure: hypoxia most likely secondary to aspiration given witnessed aspiration event, decreased o2 sats, new tachypnea, infiltrates on cxr. hap less likely since no fever or elevated wbc. cta negative for pe. other less likely etiologies include hps. finally, his respiratory support is in question at this point pending family meeting to discuss what their goals of care are, and whether extubation is within their wishes. - will d/c vanc/zosyn for hap coverage since no clear indication and may be causing drug reaction - would continue to try and switch to ps and wean as tolerated, not to plan on extubating but to assess pulmonary status - abgs as needed . # mental status changes: timing coincides with tips revision. likely multifactorial secondary to post op delirium, encephalopathy from patent tips and lack of lactulose, underlying cognitive dysfunction, and possible infection. head ct negative for bleed but his ventricles were enlarged with ? communicating hydrocephalus. per discussion with neurology, hydrocephalus unlikely cause of ms changes and is likely chronic. head ct did not show any acute signs of hemorrhage which was concern while on anticoagulation. also concern for sepsis with low uop, borderline low bps. on vanc, zosyn now for asp pna and empiric sbp treatment but will stop since no cx data, no fevers and may be causing adverse reaction with rash. para negative for sbp. ua negative. bld cx ngtd. at this point the only issue not addressed is lactulose for encephalopathy, which is impossible without ngt placement. family meeting will take place today to discuss goals of care and whether ngt is within their wishes. - unable to treat encephalopathy without ngt - on fentanyl and versed for sedation, will titrate to avoid agitation and oversedation - follow up pending cultures - discuss w/family if egd to place ngt is ok . # hypotension: hypotension likely multifactorial secondary to liver disease, ventilator and peep, rv impairment, infection/sepsis. he continues to require pressors and has minimal uop (20-30cc/hr). will add on a second pressor today and continue to monitor. there is question whether a line is [**location (un) **] accurately. - continue levophed, add vasopressin - bolus ns - follow uop - ? [**first name8 (namepattern2) 1619**] [**location (un) **] may be positional, correlate with nbp . # tips revision: had revision [**1-28**]. thrombolysis, angioplasty done with gradient of 6 after procedure was finished. per ir, no need for heparin. briefly on lovenox but discontinued since pt at risk for bleeding. ruq us demonstrates flow but could not assess gradient since agitated. - f/u further ir recs - will likely not undergo reversal given family s wishes to avoid invasive procedures . # portal vein thrombosis: s/p thrombolysis and angioplasty. - no anti-coag for now, has inr>2.0 # pacemaker malfunction/ecg changes: pacemaker not functioning properly per ep secondary to microdislodgement of rv lead per ep. has a history of high grade avb. no revision at this time. - appreciate ep recs - no nodal agents - telemetry # anemia: transfused 1 unit on this admission, hct relatively stable since around baseline and bumped appropriately to i unit. no egd since [**2119**]. theoretically, if tips patent would not need prophylaxis for varices but tips gradient unknown. if hct decreases, will consider checking [**hospital1 7**] hcts -stable . # acute renal failure: baseline cr~1. cr stable to improved, 1 today. to maintain minimal uop requires bolus ns and continued pressors. will monitor at this time and add vasopressing. - holding lasix and spironolactone - ns boluses prn low uop - maintain map 60s to maintaijn perfusion pressure - [**hospital1 7**] albumin . # gout: on colchicine . # le edema: pt had lle edema greater than r concerning for dvt. lle us negative for dvt but limited study due to agitation. lenis negative for dvt . # alcoholic cirrhosis: inactive on transplant list. - hold lasix and spironolactone given arf - appreciate hepatology recs . # thrombocytopenia: plt count stabilized, c/w prior baseline 80s-100s . # dm2: maintain glycemic control with hiss. . # fen/gi unable to feed since cannot place ngt/ogt per family request , replete lytes prn . # ppx - sub q heparin, ppi . # access - piv , rij cvl and left radial a line placed . # code dnr/dni (confirmed with pt). pt's daughter [**name (ni) 4522**] [**numeric identifier 4523**]. cell [**telephone/fax (1) 4524**] . # dispo icu; plan pending family discussion hypotension (not shock) airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) altered mental status (not delirium) alteration in nutrition .h/o alcohol withdrawal (including delirium tremens, dts, seizures) icu care nutrition: glycemic control: lines: 18 gauge - [**2124-2-1**] 11:00 am multi lumen - [**2124-2-1**] 12:49 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: dnr / dni disposition:",1
245,"chief complaint: 24 hour events: invasive ventilation - stop [**2124-2-4**] 03:30 pm made cmo by family allergies: codeine nausea/vomiting ambien (oral) (zolpidem tartrate) unknown; last dose of antibiotics: vancomycin - [**2124-2-2**] 09:39 pm piperacillin/tazobactam (zosyn) - [**2124-2-3**] 12:41 am infusions: fentanyl - 175 mcg/hour other icu medications: pantoprazole (protonix) - [**2124-2-4**] 08:32 am midazolam (versed) - [**2124-2-4**] 03:30 pm fentanyl - [**2124-2-4**] 06:17 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2124-2-5**] 05:58 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.5 c (97.7 tcurrent: 35.9 c (96.7 hr: 69 (67 - 78) bpm bp: 57/28(34) {51/23(30) - 112/43,100(85)} mmhg rr: 10 (0 - 21) insp/min spo2: 94% heart rhythm: af (atrial fibrillation) cvp: 11 (10 - 21)mmhg total in: 1,947 ml 164 ml po: tf: ivf: 1,947 ml 164 ml blood products: total out: 445 ml 25 ml urine: 445 ml 25 ml ng: stool: drains: balance: 1,502 ml 139 ml respiratory support o2 delivery device: nasal cannula ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml rr (set): 18 peep: 5 cmh2o fio2: 40% pip: 22 cmh2o plateau: 14 cmh2o spo2: 94% abg: //// ve: 9.5 l/min physical examination peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) skin: not assessed neurologic: responds to: not assessed, movement: not assessed, tone: not assessed labs / radiology 110 k/ul 10.1 g/dl 140 mg/dl 1.1 mg/dl 23 meq/l 3.9 meq/l 16 mg/dl 114 meq/l 144 meq/l 29.0 % 7.8 k/ul [image002.jpg] [**2124-2-1**] 03:52 pm [**2124-2-1**] 05:20 pm [**2124-2-1**] 08:39 pm [**2124-2-2**] 04:07 am [**2124-2-2**] 04:46 am [**2124-2-2**] 06:43 am [**2124-2-3**] 01:58 am [**2124-2-3**] 02:15 am [**2124-2-3**] 05:57 pm [**2124-2-4**] 03:24 am wbc 7.1 4.6 5.2 7.8 hct 27.6 26.7 27.1 29.0 plt 131 110 96 110 cr 1.4 1.4 1.0 1.0 1.1 tco2 20 21 23 23 24 glucose 156 175 128 138 140 other labs: pt / ptt / inr:23.5/58.0/2.3, ck / ckmb / troponin-t:468/12/0.06, alt / ast:13/34, alk phos / t bili:32/4.4, differential-neuts:78.8 %, lymph:10.7 %, mono:7.8 %, eos:2.5 %, lactic acid:1.8 mmol/l, albumin:3.7 g/dl, ldh:250 iu/l, ca++:8.7 mg/dl, mg++:1.7 mg/dl, po4:2.3 mg/dl assessment and plan 71 gentleman with alcoholic cirrhosis c/b portal htn, refractory ascites s/p tips [**2119**] found to have occluded tips by u/s in [**12-18**] now s/p tips revision [**2124-1-28**] and portal vein thrombolysis transferred with hypoxia and altered mental status now intubated with persistent hypotension and pressor requirement. . # hypoxemic respiratory failure: hypoxia most likely secondary to aspiration given witnessed aspiration event, decreased o2 sats, new tachypnea, infiltrates on cxr. hap less likely since no fever or elevated wbc. cta negative for pe. other less likely etiologies include hps. finally, his respiratory support is in question at this point pending family meeting to discuss what their goals of care are, and whether extubation is within their wishes. - will d/c vanc/zosyn for hap coverage since no clear indication and may be causing drug reaction - would continue to try and switch to ps and wean as tolerated, not to plan on extubating but to assess pulmonary status - abgs as needed . # mental status changes: timing coincides with tips revision. likely multifactorial secondary to post op delirium, encephalopathy from patent tips and lack of lactulose, underlying cognitive dysfunction, and possible infection. head ct negative for bleed but his ventricles were enlarged with ? communicating hydrocephalus. per discussion with neurology, hydrocephalus unlikely cause of ms changes and is likely chronic. head ct did not show any acute signs of hemorrhage which was concern while on anticoagulation. also concern for sepsis with low uop, borderline low bps. on vanc, zosyn now for asp pna and empiric sbp treatment but will stop since no cx data, no fevers and may be causing adverse reaction with rash. para negative for sbp. ua negative. bld cx ngtd. at this point the only issue not addressed is lactulose for encephalopathy, which is impossible without ngt placement. family meeting will take place today to discuss goals of care and whether ngt is within their wishes. - unable to treat encephalopathy without ngt - on fentanyl and versed for sedation, will titrate to avoid agitation and oversedation - follow up pending cultures - discuss w/family if egd to place ngt is ok . # hypotension: hypotension likely multifactorial secondary to liver disease, ventilator and peep, rv impairment, infection/sepsis. he continues to require pressors and has minimal uop (20-30cc/hr). will add on a second pressor today and continue to monitor. there is question whether a line is [**location (un) **] accurately. - continue levophed, add vasopressin - bolus ns - follow uop - ? [**first name8 (namepattern2) 1619**] [**location (un) **] may be positional, correlate with nbp . # tips revision: had revision [**1-28**]. thrombolysis, angioplasty done with gradient of 6 after procedure was finished. per ir, no need for heparin. briefly on lovenox but discontinued since pt at risk for bleeding. ruq us demonstrates flow but could not assess gradient since agitated. - f/u further ir recs - will likely not undergo reversal given family s wishes to avoid invasive procedures . # portal vein thrombosis: s/p thrombolysis and angioplasty. - no anti-coag for now, has inr>2.0 # pacemaker malfunction/ecg changes: pacemaker not functioning properly per ep secondary to microdislodgement of rv lead per ep. has a history of high grade avb. no revision at this time. - appreciate ep recs - no nodal agents - telemetry # anemia: transfused 1 unit on this admission, hct relatively stable since around baseline and bumped appropriately to i unit. no egd since [**2119**]. theoretically, if tips patent would not need prophylaxis for varices but tips gradient unknown. if hct decreases, will consider checking [**hospital1 7**] hcts -stable . # acute renal failure: baseline cr~1. cr stable to improved, 1 today. to maintain minimal uop requires bolus ns and continued pressors. will monitor at this time and add vasopressing. - holding lasix and spironolactone - ns boluses prn low uop - maintain map 60s to maintaijn perfusion pressure - [**hospital1 7**] albumin . # gout: on colchicine . # le edema: pt had lle edema greater than r concerning for dvt. lle us negative for dvt but limited study due to agitation. lenis negative for dvt . # alcoholic cirrhosis: inactive on transplant list. - hold lasix and spironolactone given arf - appreciate hepatology recs . # thrombocytopenia: plt count stabilized, c/w prior baseline 80s-100s . # dm2: maintain glycemic control with hiss. . # fen/gi unable to feed since cannot place ngt/ogt per family request , replete lytes prn . # ppx - sub q heparin, ppi . # access - piv , rij cvl and left radial a line placed . # code dnr/dni (confirmed with pt). pt's daughter [**name (ni) 4522**] [**numeric identifier 4523**]. cell [**telephone/fax (1) 4524**] . # dispo icu; plan pending family discussion comfort care (cmo, comfort measures) rash renal failure, acute (acute renal failure, arf) impaired skin integrity .h/o diabetes mellitus (dm), type ii hypotension (not shock) airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) altered mental status (not delirium) alteration in nutrition .h/o alcohol withdrawal (including delirium tremens, dts, seizures) icu care nutrition: glycemic control: lines: multi lumen - [**2124-2-1**] 12:49 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: comfort measures only disposition:",1
246,"chief complaint: 24 hour events: pt made dnr per family and requested no further invasive procedures or escalation of care did not have ngt placed secondary to family request decreased peep to 5 cta neg for pe lenis neg ue/le b/l sbp 70s with 15cc/hr levophed around 2 am. bolused 500cc, with uop 40 cc/hr sbp 80-90s, bolused 500cc again this am developed new rash on abdomen allergies: codeine nausea/vomiting ambien (oral) (zolpidem tartrate) unknown; last dose of antibiotics: vancomycin - [**2124-2-2**] 09:39 pm piperacillin/tazobactam (zosyn) - [**2124-2-3**] 12:41 am infusions: midazolam (versed) - 3 mg/hour fentanyl - 100 mcg/hour norepinephrine - 0.23 mcg/kg/min other icu medications: fentanyl - [**2124-2-2**] 01:33 pm midazolam (versed) - [**2124-2-2**] 05:10 pm heparin sodium (prophylaxis) - [**2124-2-2**] 08:00 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2124-2-3**] 04:42 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.2 c (97.2 tcurrent: 35.6 c (96.1 hr: 60 (57 - 74) bpm bp: 96/48(66) {85/48(62) - 112/91(279)} mmhg rr: 18 (14 - 22) insp/min spo2: 99% heart rhythm: af (atrial fibrillation) cvp: 17 (14 - 21)mmhg total in: 4,579 ml 1,483 ml po: tf: ivf: 4,479 ml 1,383 ml blood products: 100 ml 100 ml total out: 975 ml 165 ml urine: 850 ml 165 ml ng: stool: drains: 125 ml balance: 3,604 ml 1,318 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml rr (set): 18 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi deferred: agitated pip: 24 cmh2o plateau: 17 cmh2o compliance: 41.7 cmh2o/ml spo2: 99% abg: 7.36/40/95.[**numeric identifier 143**]/23/-2 ve: 9.2 l/min pao2 / fio2: 240 physical examination general: intubated, sedated, opens eyes to sternal rub, not responsive to voice or following commands, mae heent: perrl, pinpoint, op with dried blood, no e/o recent bleed neck: unable to appreciate any elevated jvp heart: rrr 2/6 systolic murmur best heard at lusb radiating to carotids lungs: coarse bs, diminished in anterior lung fields. abd: +bs, slightly hypoactive, nt, mildy distended, soft ext: trace edema b/l with chronic venous stasis changes (l>r), wwp, ue edema bl l>r neuro: limited by his mental status, spontaneously moves all 4 extremities,responsive to sternal rub . skin: multiple echymosis cta: no pe. cardiomegaly. coronary disease. small b/l effusions and atelectasis. l common carotid doesn t opacify, enlarged nodes in axilla, mediastinum, hilar. moderate ascites and cirrhosis labs / radiology 96 k/ul 9.5 g/dl 128 mg/dl 1.0 mg/dl 23 meq/l 3.3 meq/l 16 mg/dl 112 meq/l 143 meq/l 27.1 % 5.2 k/ul [image002.jpg] [**2124-2-1**] 03:02 pm [**2124-2-1**] 03:06 pm [**2124-2-1**] 03:52 pm [**2124-2-1**] 05:20 pm [**2124-2-1**] 08:39 pm [**2124-2-2**] 04:07 am [**2124-2-2**] 04:46 am [**2124-2-2**] 06:43 am [**2124-2-3**] 01:58 am [**2124-2-3**] 02:15 am wbc 7.1 4.6 5.2 hct 26.4 27.6 26.7 27.1 plt 131 110 96 cr 1.4 1.4 1.4 1.0 tco2 20 20 21 23 23 24 glucose 156 156 175 128 other labs: pt / ptt / inr:23.5/58.0/2.3, ck / ckmb / troponin-t:468/12/0.06, alt / ast:13/34, alk phos / t bili:32/4.4, differential-neuts:78.8 %, lymph:10.7 %, mono:7.8 %, eos:2.5 %, lactic acid:1.8 mmol/l, albumin:3.7 g/dl, ldh:250 iu/l, ca++:8.7 mg/dl, mg++:1.8 mg/dl, po4:2.5 mg/dl assessment and plan 71 gentleman with alcoholic cirrhosis c/b portal htn, refractory ascites s/p tips [**2119**] found to have occluded tips by u/s in [**12-18**] now s/p tips revision [**2124-1-28**] and portal vein thrombolysis transferred with hypoxia and altered mental status now intubated with persistent hypotension and pressor requirement. . # hypoxemic respiratory failure: hypoxia most likely secondary to aspiration given witnessed aspiration event, decreased o2 sats, new tachypnea, infiltrates on cxr. hap less likely since no fever or elevated wbc. also concerning for pe given rv dilation and hypokinesis but none seen on cta. other less likely etiologies include hps. - will d/c vanc/zosyn for hap coverage since no clear indication and may be causing drug reaction - would continue current vent settings for now - serial abgs to trend lactate, monitor oxygenation and ventilation - cta today to eval for pe . # mental status changes: timing coincides with tips revision. likely multifactorial secondary to post op delirium, encephalopathy from patent tips and lack of lactulose, underlying cognitive dysfunction, and possible infection. head ct negative for bleed but his ventricles were enlarged with ? communicating hydrocephalus. per discussion with neurology, hydrocephalus unlikely cause of ms changes and is likely chronic. head ct did not show any acute signs of hemorrhage which was concern while on anticoagulation. also concern for sepsis with low uop, borderline low bps. on vanc, zosyn now for asp pna and empiric sbp treatment but will stop since no cx data, no fevers and may be causing adverse reaction with rash. para negative for sbp. ua negative. bld cx ngtd. also on the differential will be alcohol withdrawal but less likely given time course, has been in hospital since [**1-21**] and only received ativan after tips on [**1-28**]. - unable to treat encephalopathy without ngt - on fentanyl and versed for sedation, will titrate to avoid agitation and oversedation - follow up blood cx, urine cx, ascetic cx, obtain sputum cx and restart abx if indicated - could consider occluding tips if unable to reverse ms changes but family not interested in invasive procedures . # hypotension: hypotension likely multifactorial secondary to liver disease, ventilator and peep, rv impairment, infection/sepsis. - continue pressors (currently on levophed) titrate to lower map 60s - would not add second pressor without family discussion regarding management, just bolus for now, accept lower bps - follow uop # tips revision: had revision [**1-28**]. thrombolysis, angioplasty done with gradient of 6 after procedure was finished. per ir, no need for heparin. briefly on lovenox but discontinued since pt at risk for bleeding. ruq us demonstrates flow but could not assess gradient since agitated. - f/u further ir recs - consider reversing tips due to gross encephalopathy but pt s family does not want further invasive procedures . # portal vein thrombosis: s/p thrombolysis and angioplasty. - no anti-coag for now, has inr>2.0 # pacemaker malfunction/ecg changes: pacemaker not functioning properly per ep secondary to microdislodgement of rv lead per ep. has a history of high grade avb. if recovers, will need lead revision. - appreciate ep recs - no nodal agents - telemetry # anemia: transfused 1 unit on this admission, hct relatively stable since around baseline and bumped appropriately to i unit. no egd since [**2119**]. theoretically, if tips patent would not need prophylaxis for varices but tips gradient unknown. if hct decreases, will consider checking [**hospital1 7**] hcts . # acute renal failure: baseline cr~1. cr stable to improved, 1 today. has had good uop last 24 hours, requiring boluses x 2 for low uop and bp but seems to respond well to this. - holding lasix and spironolactone - ns boluses prn low uop - maintain map 60s to maintaijn perfusion pressure - [**hospital1 7**] albumin . # gout: on colchicine . # le edema: pt had lle edema greater than r concerning for dvt. lle us negative for dvt but limited study due to agitation. lenis negative for dvt . # alcoholic cirrhosis: inactive on transplant list. - hold lasix and spironolactone given arf - appreciate hepatology recs . # thrombocytopenia: plt count stabilized, c/w prior baseline 80s-100s . # dm2: maintain glycemic control with hiss. . # fen/gi unable to feed since cannot place ngt/ogt per pt request , replete lytes prn . # ppx - sub q heparin, ppi . # access - piv , rij cvl and left radial a line placed . # code - full (confirmed with pt). pt's daughter [**name (ni) 4522**] [**numeric identifier 4523**]. cell [**telephone/fax (1) 4524**] . # dispo - pending improvement in mental status hypotension (not shock) airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) altered mental status (not delirium) alteration in nutrition .h/o alcohol withdrawal (including delirium tremens, dts, seizures) icu care nutrition: glycemic control: lines: 18 gauge - [**2124-2-1**] 11:00 am multi lumen - [**2124-2-1**] 12:49 pm arterial line - [**2124-2-1**] 12:50 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: dnr / dni disposition:",1
247,"chief complaint: 24 hour events: pt made dnr per family and requested no further invasive procedures or escalation of care did not have ngt placed secondary to family request decreased peep to 5 cta neg for pe lenis neg ue/le b/l sbp 70s with 15cc/hr levophed around 2 am. bolused 500cc, with uop 40 cc/hr sbp 80-90s, bolused 500cc again this am developed new rash on abdomen allergies: codeine nausea/vomiting ambien (oral) (zolpidem tartrate) unknown; last dose of antibiotics: vancomycin - [**2124-2-2**] 09:39 pm piperacillin/tazobactam (zosyn) - [**2124-2-3**] 12:41 am infusions: midazolam (versed) - 3 mg/hour fentanyl - 100 mcg/hour norepinephrine - 0.23 mcg/kg/min other icu medications: fentanyl - [**2124-2-2**] 01:33 pm midazolam (versed) - [**2124-2-2**] 05:10 pm heparin sodium (prophylaxis) - [**2124-2-2**] 08:00 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2124-2-3**] 04:42 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.2 c (97.2 tcurrent: 35.6 c (96.1 hr: 60 (57 - 74) bpm bp: 96/48(66) {85/48(62) - 112/91(279)} mmhg rr: 18 (14 - 22) insp/min spo2: 99% heart rhythm: af (atrial fibrillation) cvp: 17 (14 - 21)mmhg total in: 4,579 ml 1,483 ml po: tf: ivf: 4,479 ml 1,383 ml blood products: 100 ml 100 ml total out: 975 ml 165 ml urine: 850 ml 165 ml ng: stool: drains: 125 ml balance: 3,604 ml 1,318 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml rr (set): 18 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi deferred: agitated pip: 24 cmh2o plateau: 17 cmh2o compliance: 41.7 cmh2o/ml spo2: 99% abg: 7.36/40/95.[**numeric identifier 143**]/23/-2 ve: 9.2 l/min pao2 / fio2: 240 physical examination general: intubated, sedated, opens eyes to sternal rub, not responsive to voice or following commands, mae heent: perrl, pinpoint, op with dried blood, no e/o recent bleed neck: unable to appreciate any elevated jvp heart: rrr 2/6 systolic murmur best heard at lusb radiating to carotids lungs: coarse bs, diminished in anterior lung fields. abd: +bs, slightly hypoactive, nt, mildy distended, soft ext: trace edema b/l with chronic venous stasis changes (l>r), wwp, ue edema bl l>r neuro: limited by his mental status, spontaneously moves all 4 extremities,responsive to sternal rub . skin: multiple echymosis cta: no pe. cardiomegaly. coronary disease. small b/l effusions and atelectasis. l common carotid doesn t opacify, enlarged nodes in axilla, mediastinum, hilar. moderate ascites and cirrhosis labs / radiology 96 k/ul 9.5 g/dl 128 mg/dl 1.0 mg/dl 23 meq/l 3.3 meq/l 16 mg/dl 112 meq/l 143 meq/l 27.1 % 5.2 k/ul [image002.jpg] [**2124-2-1**] 03:02 pm [**2124-2-1**] 03:06 pm [**2124-2-1**] 03:52 pm [**2124-2-1**] 05:20 pm [**2124-2-1**] 08:39 pm [**2124-2-2**] 04:07 am [**2124-2-2**] 04:46 am [**2124-2-2**] 06:43 am [**2124-2-3**] 01:58 am [**2124-2-3**] 02:15 am wbc 7.1 4.6 5.2 hct 26.4 27.6 26.7 27.1 plt 131 110 96 cr 1.4 1.4 1.4 1.0 tco2 20 20 21 23 23 24 glucose 156 156 175 128 other labs: pt / ptt / inr:23.5/58.0/2.3, ck / ckmb / troponin-t:468/12/0.06, alt / ast:13/34, alk phos / t bili:32/4.4, differential-neuts:78.8 %, lymph:10.7 %, mono:7.8 %, eos:2.5 %, lactic acid:1.8 mmol/l, albumin:3.7 g/dl, ldh:250 iu/l, ca++:8.7 mg/dl, mg++:1.8 mg/dl, po4:2.5 mg/dl assessment and plan 71 gentleman with alcoholic cirrhosis c/b portal htn, refractory ascites s/p tips [**2119**] found to have occluded tips by u/s in [**12-18**] now s/p tips revision [**2124-1-28**] and portal vein thrombolysis transferred with hypoxia and altered mental status now intubated with persistent hypotension and pressor requirement. . # hypoxemic respiratory failure: hypoxia most likely secondary to aspiration given witnessed aspiration event, decreased o2 sats, new tachypnea, infiltrates on cxr. hap less likely since no fever or elevated wbc. also concerning for pe given rv dilation and hypokinesis but none seen on cta. other less likely etiologies include hps. - will d/c vanc/zosyn for hap coverage since no clear indication and may be causing drug reaction - would continue current vent settings for now - serial abgs to trend lactate, monitor oxygenation and ventilation - cta today to eval for pe . # mental status changes: timing coincides with tips revision. likely multifactorial secondary to post op delirium, encephalopathy from patent tips and lack of lactulose, underlying cognitive dysfunction, and possible infection. head ct negative for bleed but his ventricles were enlarged with ? communicating hydrocephalus. per discussion with neurology, hydrocephalus unlikely cause of ms changes and is likely chronic. head ct did not show any acute signs of hemorrhage which was concern while on anticoagulation. also concern for sepsis with low uop, borderline low bps. on vanc, zosyn now for asp pna and empiric sbp treatment but will stop since no cx data, no fevers and may be causing adverse reaction with rash. para negative for sbp. ua negative. bld cx ngtd. also on the differential will be alcohol withdrawal but less likely given time course, has been in hospital since [**1-21**] and only received ativan after tips on [**1-28**]. - unable to treat encephalopathy without ngt - on fentanyl and versed for sedation, will titrate to avoid agitation and oversedation - follow up blood cx, urine cx, ascetic cx, obtain sputum cx and restart abx if indicated - could consider occluding tips if unable to reverse ms changes but family not interested in invasive procedures . # hypotension: hypotension likely multifactorial secondary to liver disease, ventilator and peep, rv impairment, infection/sepsis. - continue pressors (currently on levophed) titrate to lower map 60s - would not add second pressor without family discussion regarding management, just bolus for now, accept lower bps - follow uop # tips revision: had revision [**1-28**]. thrombolysis, angioplasty done with gradient of 6 after procedure was finished. per ir, no need for heparin. briefly on lovenox but discontinued since pt at risk for bleeding. ruq us demonstrates flow but could not assess gradient since agitated. - f/u further ir recs - consider reversing tips due to gross encephalopathy but pt s family does not want further invasive procedures . # portal vein thrombosis: s/p thrombolysis and angioplasty. - no anti-coag for now, has inr>2.0 # pacemaker malfunction/ecg changes: pacemaker not functioning properly per ep secondary to microdislodgement of rv lead per ep. has a history of high grade avb. if recovers, will need lead revision. - appreciate ep recs - no nodal agents - telemetry # anemia: transfused 1 unit on this admission, hct relatively stable since around baseline and bumped appropriately to i unit. no egd since [**2119**]. theoretically, if tips patent would not need prophylaxis for varices but tips gradient unknown. if hct decreases, will consider checking [**hospital1 7**] hcts . # acute renal failure: baseline cr~1. cr stable to improved, 1 today. has had good uop last 24 hours, requiring boluses x 2 for low uop and bp but seems to respond well to this. - holding lasix and spironolactone - ns boluses prn low uop - maintain map 60s to maintaijn perfusion pressure - [**hospital1 7**] albumin . # gout: on colchicine . # le edema: pt had lle edema greater than r concerning for dvt. lle us negative for dvt but limited study due to agitation. lenis negative for dvt . # alcoholic cirrhosis: inactive on transplant list. - hold lasix and spironolactone given arf - appreciate hepatology recs . # thrombocytopenia: plt count stabilized, c/w prior baseline 80s-100s . # dm2: maintain glycemic control with hiss. . # fen/gi unable to feed since cannot place ngt/ogt per pt request , replete lytes prn . # ppx - sub q heparin, ppi . # access - piv , rij cvl and left radial a line placed . # code - full (confirmed with pt). pt's daughter [**name (ni) 4522**] [**numeric identifier 4523**]. cell [**telephone/fax (1) 4524**] . # dispo - pending improvement in mental status hypotension (not shock) airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) altered mental status (not delirium) alteration in nutrition .h/o alcohol withdrawal (including delirium tremens, dts, seizures) icu care nutrition: glycemic control: lines: 18 gauge - [**2124-2-1**] 11:00 am multi lumen - [**2124-2-1**] 12:49 pm arterial line - [**2124-2-1**] 12:50 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: dnr / dni disposition: ------ protected section ------ micu attending addendum i saw and examined the patient, and was physically present with the icu team for the key portions of the services provided. i agree with the note above, including the assessment and plan. i would emphasize and add the following points: 71m etoh cirrhosis, tips [**1-28**] for refractory ascites, progressive encephalopathy, hypoxemia following attempted ngt placement. intubated, cvl, a-line, s/p paracentesis w/subseq pressor requirement. events family mtg [**2-2**] - determined to be dnr, if not improving [**2-3**] then ?cmo [**2-4**]. will reassess after family meeting [**2-4**]. chest cta showed no pe, sm bilat pleural effusions. lenis neg for dvt. hypotensive overnight s/p bolus x 2, increased levophed. exam notable for elderly gentleman, intubated and sedated no response to voice. tm 96.1 bp 125/70 hr 87af rr 18 with sat 95 on vac 500x18 5 0.4 7.36/40/93. diffuse rhonchi, irreg s1s2 2/6sm. distended, tympanitic abdomen. 2+ edema upper > lower extremities. erythematous rash on abdomen. labs notable for wbc 5k, hct 27, k+ 3.3, cr 1.0, na 143, inr 2.3. cxr with l>r lung asd changes. agree with plan to reassess today/tomorrow after repeat family meeting. given new rash will stop antibiotics. no evidence for pe/dvt. will manage encephalopathy with endoscopic ngt placement, lactulose, rifaximin, and reversal of hypernatremia. no evidence of sbp. care and overall prognosis reviewed with daughter yesterday. [**name2 (ni) **] would not want chronic support, but will continue with current level of care in an effort to reverse encephalopathy. currently we are not giving supplemental feeds and this will need to be readdressed if plan to continue current therapy is decided in tomorrow s meeting. remainder of plan as outlined above. discussed with brother of patient today. patient is critically ill total time: 50 min ------ protected section addendum entered by:[**name (ni) 20**] [**last name (namepattern1) 885**], md on:[**2124-2-3**] 12:06 ------",1
248,"chief complaint: 24 hour events: arterial line - stop [**2124-2-4**] 12:00 am made dnr yesterday. no more invasive procedures. family considering cmo. allergies: codeine nausea/vomiting ambien (oral) (zolpidem tartrate) unknown; last dose of antibiotics: vancomycin - [**2124-2-2**] 09:39 pm piperacillin/tazobactam (zosyn) - [**2124-2-3**] 12:41 am infusions: midazolam (versed) - 3 mg/hour fentanyl - 100 mcg/hour norepinephrine - 0.24 mcg/kg/min other icu medications: pantoprazole (protonix) - [**2124-2-3**] 08:04 pm midazolam (versed) - [**2124-2-4**] 12:06 am fentanyl - [**2124-2-4**] 12:07 am heparin sodium (prophylaxis) - [**2124-2-4**] 04:27 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2124-2-4**] 05:42 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.9 c (98.5 tcurrent: 35.8 c (96.5 hr: 70 (65 - 78) bpm bp: 113/65(77) {62/42(47) - 125/74(83)} mmhg rr: 17 (16 - 22) insp/min spo2: 98% heart rhythm: af (atrial fibrillation) cvp: 12 (8 - 17)mmhg total in: 4,163 ml 420 ml po: tf: ivf: 3,963 ml 420 ml blood products: 200 ml total out: 765 ml 170 ml urine: 765 ml 170 ml ng: stool: drains: balance: 3,398 ml 250 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml rr (set): 18 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi deferred: neuromusc block pip: 19 cmh2o plateau: 14 cmh2o compliance: 55.6 cmh2o/ml spo2: 98% abg: ///23/ ve: 8.9 l/min physical examination general: intubated, sedated, opens eyes to sternal rub, not responsive to voice or following commands, mae heent: perrl, pinpoint, op with dried blood, no e/o recent bleed neck: unable to appreciate any elevated jvp heart: rrr 2/6 systolic murmur best heard at lusb radiating to carotids lungs: coarse bs, diminished in anterior lung fields. abd: +bs, slightly hypoactive, nt, mildy distended, soft ext: trace edema b/l with chronic venous stasis changes (l>r), wwp, ue edema bl l>r neuro: limited by his mental status, spontaneously moves all 4 extremities,responsive to sternal rub . skin: multiple echymosis labs / radiology 110 k/ul 10.1 g/dl 140 mg/dl 1.1 mg/dl 23 meq/l 3.9 meq/l 16 mg/dl 114 meq/l 144 meq/l 29.0 % 7.8 k/ul [image002.jpg] [**2124-2-1**] 03:52 pm [**2124-2-1**] 05:20 pm [**2124-2-1**] 08:39 pm [**2124-2-2**] 04:07 am [**2124-2-2**] 04:46 am [**2124-2-2**] 06:43 am [**2124-2-3**] 01:58 am [**2124-2-3**] 02:15 am [**2124-2-3**] 05:57 pm [**2124-2-4**] 03:24 am wbc 7.1 4.6 5.2 7.8 hct 27.6 26.7 27.1 29.0 plt 131 110 96 110 cr 1.4 1.4 1.0 1.0 1.1 tco2 20 21 23 23 24 glucose 156 175 128 138 140 other labs: pt / ptt / inr:23.5/58.0/2.3, ck / ckmb / troponin-t:468/12/0.06, alt / ast:13/34, alk phos / t bili:32/4.4, differential-neuts:78.8 %, lymph:10.7 %, mono:7.8 %, eos:2.5 %, lactic acid:1.8 mmol/l, albumin:3.7 g/dl, ldh:250 iu/l, ca++:8.7 mg/dl, mg++:1.7 mg/dl, po4:2.3 mg/dl assessment and plan 71 gentleman with alcoholic cirrhosis c/b portal htn, refractory ascites s/p tips [**2119**] found to have occluded tips by u/s in [**12-18**] now s/p tips revision [**2124-1-28**] and portal vein thrombolysis transferred with hypoxia and altered mental status now intubated with persistent hypotension and pressor requirement. . # hypoxemic respiratory failure: hypoxia most likely secondary to aspiration given witnessed aspiration event, decreased o2 sats, new tachypnea, infiltrates on cxr. hap less likely since no fever or elevated wbc. also concerning for pe given rv dilation and hypokinesis but none seen on cta. other less likely etiologies include hps. - will d/c vanc/zosyn for hap coverage since no clear indication and may be causing drug reaction - would continue current vent settings for now - serial abgs to trend lactate, monitor oxygenation and ventilation - cta today to eval for pe . # mental status changes: timing coincides with tips revision. likely multifactorial secondary to post op delirium, encephalopathy from patent tips and lack of lactulose, underlying cognitive dysfunction, and possible infection. head ct negative for bleed but his ventricles were enlarged with ? communicating hydrocephalus. per discussion with neurology, hydrocephalus unlikely cause of ms changes and is likely chronic. head ct did not show any acute signs of hemorrhage which was concern while on anticoagulation. also concern for sepsis with low uop, borderline low bps. on vanc, zosyn now for asp pna and empiric sbp treatment but will stop since no cx data, no fevers and may be causing adverse reaction with rash. para negative for sbp. ua negative. bld cx ngtd. also on the differential will be alcohol withdrawal but less likely given time course, has been in hospital since [**1-21**] and only received ativan after tips on [**1-28**]. - unable to treat encephalopathy without ngt - on fentanyl and versed for sedation, will titrate to avoid agitation and oversedation - follow up blood cx, urine cx, ascetic cx, obtain sputum cx and restart abx if indicated - could consider occluding tips if unable to reverse ms changes but family not interested in invasive procedures . # hypotension: hypotension likely multifactorial secondary to liver disease, ventilator and peep, rv impairment, infection/sepsis. - continue pressors (currently on levophed) titrate to lower map 60s - would not add second pressor without family discussion regarding management, just bolus for now, accept lower bps - follow uop # tips revision: had revision [**1-28**]. thrombolysis, angioplasty done with gradient of 6 after procedure was finished. per ir, no need for heparin. briefly on lovenox but discontinued since pt at risk for bleeding. ruq us demonstrates flow but could not assess gradient since agitated. - f/u further ir recs - consider reversing tips due to gross encephalopathy but pt s family does not want further invasive procedures . # portal vein thrombosis: s/p thrombolysis and angioplasty. - no anti-coag for now, has inr>2.0 # pacemaker malfunction/ecg changes: pacemaker not functioning properly per ep secondary to microdislodgement of rv lead per ep. has a history of high grade avb. if recovers, will need lead revision. - appreciate ep recs - no nodal agents - telemetry # anemia: transfused 1 unit on this admission, hct relatively stable since around baseline and bumped appropriately to i unit. no egd since [**2119**]. theoretically, if tips patent would not need prophylaxis for varices but tips gradient unknown. if hct decreases, will consider checking [**hospital1 7**] hcts . # acute renal failure: baseline cr~1. cr stable to improved, 1 today. has had good uop last 24 hours, requiring boluses x 2 for low uop and bp but seems to respond well to this. - holding lasix and spironolactone - ns boluses prn low uop - maintain map 60s to maintaijn perfusion pressure - [**hospital1 7**] albumin . # gout: on colchicine . # le edema: pt had lle edema greater than r concerning for dvt. lle us negative for dvt but limited study due to agitation. lenis negative for dvt . # alcoholic cirrhosis: inactive on transplant list. - hold lasix and spironolactone given arf - appreciate hepatology recs . # thrombocytopenia: plt count stabilized, c/w prior baseline 80s-100s . # dm2: maintain glycemic control with hiss. . # fen/gi unable to feed since cannot place ngt/ogt per pt request , replete lytes prn . # ppx - sub q heparin, ppi . # access - piv , rij cvl and left radial a line placed . # code - full (confirmed with pt). pt's daughter [**name (ni) 4522**] [**numeric identifier 4523**]. cell [**telephone/fax (1) 4524**] . # dispo - pending improvement in mental status hypotension (not shock) airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) altered mental status (not delirium) alteration in nutrition .h/o alcohol withdrawal (including delirium tremens, dts, seizures) icu care nutrition: glycemic control: lines: 18 gauge - [**2124-2-1**] 11:00 am multi lumen - [**2124-2-1**] 12:49 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: dnr / dni disposition:",1
249,"chief complaint: 24 hour events: - extubated patient - lenis showed - deep vein thrombosis identified in the right popliteal vein - uelis negative - mri brain -> findings suggestive of dural-based metastatic disease bifrontally, right greater than left, which may invade the anterior aspect of the sagittal sinus. there is an extra-axial lesion in the left frontal lobe which may represent metastatic disease or meningioma. no evidence of hemorrhage. - cardiac echo - ef 30%, the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is top normal/borderline dilated. no masses or thrombi are seen in the left ventricle. overall left ventricular systolic function is moderately depressed (lvef= 30 %) with inferior, infero-lateral and apical akinesis. there is no ventricular septal defect. with mild global free wall hypokinesis. the ascending aorta is mildly dilated. 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. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. - resumed regular diet, no need for tube feeds since extubated - will discuss goals of care with patient since she has capacity, ask her re anticoagulation vs filter placement allergies: penicillins rash; codeine nausea/vomiting last dose of antibiotics: vancomycin - [**2157-1-31**] 04:30 am cefipime - [**2157-2-1**] 02:12 am infusions: heparin sodium - 700 units/hour other icu medications: pantoprazole (protonix) - [**2157-2-1**] 06:15 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2157-2-1**] 06:53 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.8 c (98.3 tcurrent: 36 c (96.8 hr: 95 (56 - 109) bpm bp: 118/61(81) {95/36(56) - 139/81(104)} mmhg rr: 20 (13 - 25) insp/min spo2: 98% heart rhythm: sr (sinus rhythm) cvp: 7 (6 - 7)mmhg total in: 8,355 ml 927 ml po: tf: ivf: 5,355 ml 927 ml blood products: total out: 430 ml 150 ml urine: 430 ml 150 ml ng: stool: drains: balance: 7,925 ml 777 ml respiratory support o2 delivery device: nasal cannula ventilator mode: cpap/psv vt (spontaneous): 427 (415 - 427) ml ps : 8 cmh2o rr (spontaneous): 20 peep: 5 cmh2o fio2: 40% pip: 14 cmh2o spo2: 98% abg: 7.34/31/82.[**numeric identifier 143**]/18/-7 ve: 9.6 l/min physical examination general: nad, tired, extubated heent: pupils are equal, round, and reactive to light. mm dry lungs: clear to ausculation bilaterally, no w/r heart: regular, prominent p2, no apprec murmur abdomen: soft, mildly distended, nabs, nttp, no rebound extremities: cool, distal pulses +2, left hand erythematous, edematous and cool, radial pulse dopplerable neurologic: following commands, moving all 4 extremities and easily arousable labs / radiology 242 k/ul 8.1 g/dl 88 mg/dl 1.4 mg/dl 18 meq/l 3.9 meq/l 26 mg/dl 115 meq/l 141 meq/l 23.9 % 3.4 k/ul [image002.jpg] [**2157-1-31**] 03:01 am [**2157-1-31**] 10:24 am [**2157-1-31**] 10:39 am [**2157-1-31**] 05:09 pm [**2157-1-31**] 05:30 pm [**2157-1-31**] 08:47 pm [**2157-2-1**] 01:01 am [**2157-2-1**] 06:21 am wbc 5.3 3.4 hct 27.0 23.9 plt 355 242 cr 1.3 1.4 tropt 3.73 3.99 tco2 17 19 19 18 17 glucose 163 88 other labs: pt / ptt / inr:15.6/86.8/1.4, ck / ckmb / troponin-t:1111/192/3.99, alt / ast:400/541, alk phos / t bili:403/2.1, lactic acid:1.3 mmol/l, ldh:919 iu/l, ca++:7.8 mg/dl, mg++:2.4 mg/dl, po4:4.0 mg/dl assessment and plan 82 y/o f with cad s/p cabg and metastatic breast cancer who presented with fever and sob, found to have bilateral pes and now s/p vfib arrest, intubated and following commands. . # s/p pea arrest: pt with metastatic breast ca who p/w fever and found to have bilateral pes, went into vfib/pea arrest, coded and converted to sinus tach. most likely etiology for arrest was pe and cardiac strain, now with positive enzyme's consistent with nstemi/rv strain. pt was not a candidate for lysis given possible hemorrhagic mets. - continue heparin gtt goal ptt 60-80 - off of levophed - replace lytes aggressively . # acute pe/resp failure: pt presented with fever & found to have bilateral pes, subsequently developped vfib arrest. lysis contra-indicated due to hemorrhagic mets. resp status was stable until vfib arrest, now s/p intubation and extubation. - heparin gtt with goal ptt 60-80 - echo showed lvef 30%, rv dysfunction and pah - dvt in r popliteal - will discuss with pt and dr. [**last name (stitle) 4309**] possibilities for long-term anticoagulation/ivc filter/no treatment - increased r-sided pleural effusion in the setting of aggressive resuscitation -> will diurese with lasix, titrate to map > 60 - add nebs . # nstemi: pt with bilateral pes and positive cardiac enzymes most likely due to rv strain/infarct. much less likely to have had acute acs with simultaneous pes. however, pt with known cad s/p remote cabg and now with inferolateral st changes with positive ck/mb/troponins. pt was denying cp on admission and ce positive prior to code - trop-t peaked at 3.99, ck-mb 192 - continue heparin gtt - continue aspirin 325mg daily - cont metoprolol 12.5mg [**hospital1 7**] once weaned from pressors - hold off on statin given acute transaminitis - echo showed lvef 30%, rv dysfunction and pah . # fever: etiology unclear, though may have been due to acute pes. cxr essentially unchanged from prior, ua neg and blood cx sent. given recent chemo and neutropenia, pt received cefepime for possible neutropenic fever. now s/p code with intubation, will cover broadly empirically and plan to stop in 48hrs if all cx negative. - gram stain shows no organisms, clinical picture does not appear consistent with pna -> d/c vanc & cefepime - f/u urine/blood/sputum cx - f/u cxr in am . # elevated lfts: pt was noted to have new transaminitis and worsening of obstructive pattern prior to code. ruq u/s was negative for acute cholecystitis. this may be due to worsening liver mets, congestive hepatopathy, adverse reaction to chemo - trend lfts - holding statin for now - t/b with primary onc regarding navelbine . # metastatic breast cancer- pt with known progression of her disease on capecitabine, currently on navelbine, although recent cycle was held for neutropenia. ct head revealed new lesions concerning for hemorrhagic mets. - d/w with primary onc dr. [**first name4 (namepattern1) 1045**] [**last name (namepattern1) 4309**], options for chemo/radiation . # hypertension: - will start on low dose metoprolol . # hyperlipidemia- holding home statin given acute transaminitis . # anemia - stable anemia on chem, trend hct given gastroccult positive emesis (not coffee grounds) - maintain active type/cross. . # fen- reg diet, replete lytes prn . # prophylaxis - heparin gtt, ppi, bowel regimen . # code status: full . # dispo: hem/onc (east) icu care nutrition: glycemic control: lines: 18 gauge - [**2157-1-31**] 12:43 am 20 gauge - [**2157-1-31**] 12:43 am multi lumen - [**2157-1-31**] 12:44 am arterial line - [**2157-1-31**] 08:30 am prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition: ------ protected section ------ attending addendum: i saw and examined the patient, and was physically present with the icu resident for key portions of the services provided. i agree with his / her note above, including assessment and plan. pmh, sh, fh and ros are unchanged from admission except where noted above and below. key points: continues on heparin drip for pe, dvt c/o dyspnea, discomfort cxr with larger right pleural effusion exam sig for mild distress, breathing with accessory muscles. oxygenating well on 3l nc. cta posterior except dullness at right base, wheezing anteriorly. heart sounds nearly inaudible with loud wheezing. abd soft, ndnt. 2+ peripheral edema in hands, nonpitting in le. * diurese, titrate to bp * try neb for wheezing, though no known h/o copd * no indication for thoracentesis- hopefully effusion will improve with diuresis * d/c antibiotics safe for tx to onc floor- will need further discussion regarding goals of care, continued anticoagulation, education regarding rv failure ------ protected section addendum entered by:[**name (ni) 457**] [**last name (namepattern1) **], md on:[**2157-2-1**] 13:42 ------",1
250,"chief complaint: 24 hour events: - extubated patient - lenis showed - deep vein thrombosis identified in the right popliteal vein - uelis negative - mri brain -> findings suggestive of dural-based metastatic disease bifrontally, right greater than left, which may invade the anterior aspect of the sagittal sinus. there is an extra-axial lesion in the left frontal lobe which may represent metastatic disease or meningioma. no evidence of hemorrhage. - cardiac echo - ef 30%, the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is top normal/borderline dilated. no masses or thrombi are seen in the left ventricle. overall left ventricular systolic function is moderately depressed (lvef= 30 %) with inferior, infero-lateral and apical akinesis. there is no ventricular septal defect. with mild global free wall hypokinesis. the ascending aorta is mildly dilated. 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. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. - resumed regular diet, no need for tube feeds since extubated - will discuss goals of care with patient since she has capacity, ask her re anticoagulation vs filter placement allergies: penicillins rash; codeine nausea/vomiting last dose of antibiotics: vancomycin - [**2157-1-31**] 04:30 am cefipime - [**2157-2-1**] 02:12 am infusions: heparin sodium - 700 units/hour other icu medications: pantoprazole (protonix) - [**2157-2-1**] 06:15 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2157-2-1**] 06:53 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.8 c (98.3 tcurrent: 36 c (96.8 hr: 95 (56 - 109) bpm bp: 118/61(81) {95/36(56) - 139/81(104)} mmhg rr: 20 (13 - 25) insp/min spo2: 98% heart rhythm: sr (sinus rhythm) cvp: 7 (6 - 7)mmhg total in: 8,355 ml 927 ml po: tf: ivf: 5,355 ml 927 ml blood products: total out: 430 ml 150 ml urine: 430 ml 150 ml ng: stool: drains: balance: 7,925 ml 777 ml respiratory support o2 delivery device: nasal cannula ventilator mode: cpap/psv vt (spontaneous): 427 (415 - 427) ml ps : 8 cmh2o rr (spontaneous): 20 peep: 5 cmh2o fio2: 40% pip: 14 cmh2o spo2: 98% abg: 7.34/31/82.[**numeric identifier 143**]/18/-7 ve: 9.6 l/min physical examination general: nad, tired, extubated heent: pupils are equal, round, and reactive to light. mm dry lungs: clear to ausculation bilaterally, no w/r heart: regular, prominent p2, no apprec murmur abdomen: soft, mildly distended, nabs, nttp, no rebound extremities: cool, distal pulses +2, left hand erythematous, edematous and cool, radial pulse dopplerable neurologic: following commands, moving all 4 extremities and easily arousable labs / radiology 242 k/ul 8.1 g/dl 88 mg/dl 1.4 mg/dl 18 meq/l 3.9 meq/l 26 mg/dl 115 meq/l 141 meq/l 23.9 % 3.4 k/ul [image002.jpg] [**2157-1-31**] 03:01 am [**2157-1-31**] 10:24 am [**2157-1-31**] 10:39 am [**2157-1-31**] 05:09 pm [**2157-1-31**] 05:30 pm [**2157-1-31**] 08:47 pm [**2157-2-1**] 01:01 am [**2157-2-1**] 06:21 am wbc 5.3 3.4 hct 27.0 23.9 plt 355 242 cr 1.3 1.4 tropt 3.73 3.99 tco2 17 19 19 18 17 glucose 163 88 other labs: pt / ptt / inr:15.6/86.8/1.4, ck / ckmb / troponin-t:1111/192/3.99, alt / ast:400/541, alk phos / t bili:403/2.1, lactic acid:1.3 mmol/l, ldh:919 iu/l, ca++:7.8 mg/dl, mg++:2.4 mg/dl, po4:4.0 mg/dl assessment and plan 82 y/o f with cad s/p cabg and metastatic breast cancer who presented with fever and sob, found to have bilateral pes and now s/p vfib arrest, intubated and following commands. . # s/p pea arrest: pt with metastatic breast ca who p/w fever and found to have bilateral pes, went into vfib/pea arrest, coded and converted to sinus tach. most likely etiology for arrest was pe and cardiac strain, now with positive enzyme's consistent with nstemi/rv strain. pt was not a candidate for lysis given possible hemorrhagic mets. - continue heparin gtt goal ptt 60-80 - off of levophed - replace lytes aggressively . # acute pe/resp failure: pt presented with fever & found to have bilateral pes, subsequently developped vfib arrest. lysis contra-indicated due to hemorrhagic mets. resp status was stable until vfib arrest, now s/p intubation and extubation. - heparin gtt with goal ptt 60-80 - echo showed lvef 30%, rv dysfunction and pah - dvt in r popliteal - will discuss with pt and dr. [**last name (stitle) 4309**] possibilities for long-term anticoagulation/ivc filter/no treatment - increased r-sided pleural effusion in the setting of aggressive resuscitation -> will diurese with lasix, titrate to map > 60 - add nebs . # nstemi: pt with bilateral pes and positive cardiac enzymes most likely due to rv strain/infarct. much less likely to have had acute acs with simultaneous pes. however, pt with known cad s/p remote cabg and now with inferolateral st changes with positive ck/mb/troponins. pt was denying cp on admission and ce positive prior to code - trop-t peaked at 3.99, ck-mb 192 - continue heparin gtt - continue aspirin 325mg daily - cont metoprolol 12.5mg [**hospital1 7**] once weaned from pressors - hold off on statin given acute transaminitis - echo showed lvef 30%, rv dysfunction and pah . # fever: etiology unclear, though may have been due to acute pes. cxr essentially unchanged from prior, ua neg and blood cx sent. given recent chemo and neutropenia, pt received cefepime for possible neutropenic fever. now s/p code with intubation, will cover broadly empirically and plan to stop in 48hrs if all cx negative. - gram stain shows no organisms, clinical picture does not appear consistent with pna -> d/c vanc & cefepime - f/u urine/blood/sputum cx - f/u cxr in am . # elevated lfts: pt was noted to have new transaminitis and worsening of obstructive pattern prior to code. ruq u/s was negative for acute cholecystitis. this may be due to worsening liver mets, congestive hepatopathy, adverse reaction to chemo - trend lfts - holding statin for now - t/b with primary onc regarding navelbine . # metastatic breast cancer- pt with known progression of her disease on capecitabine, currently on navelbine, although recent cycle was held for neutropenia. ct head revealed new lesions concerning for hemorrhagic mets. - d/w with primary onc dr. [**first name4 (namepattern1) 1045**] [**last name (namepattern1) 4309**], options for chemo/radiation . # hypertension: - will start on low dose metoprolol . # hyperlipidemia- holding home statin given acute transaminitis . # anemia - stable anemia on chem, trend hct given gastroccult positive emesis (not coffee grounds) - maintain active type/cross. . # fen- reg diet, replete lytes prn . # prophylaxis - heparin gtt, ppi, bowel regimen . # code status: full . # dispo: hem/onc (east) icu care nutrition: glycemic control: lines: 18 gauge - [**2157-1-31**] 12:43 am 20 gauge - [**2157-1-31**] 12:43 am multi lumen - [**2157-1-31**] 12:44 am arterial line - [**2157-1-31**] 08:30 am prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",1
251,"pt. is a 47 year old primarly cambodian speaking woman with a history of neuromyelitis optica (ab neg) with transverse myelitis and baseline right eye blindness diagnosed 18 months ago. last admission was [**2137-11-11**] for new flare in the context of a e-coli uti. she has been treated with rituximab in the past. she now presents with worsening right sided weakness and numbness plus new left sided weakness and numbness and new urinary/bowel incontinence. pt. was taken first to [**hospital 4725**] hospital ed, then transfered to [**hospital1 19**] on [**12-23**] at which time she received rituximab infusion which she did not tolerate. she is being transfered to the micu today for rituximab desensitization. .h/o adverse drug event (adr, ade, medication toxicity) assessment: pt. complaining of slight itchiness prior to administration of any medications upon arrival to micu. action: pt. premedicated with benadryl and pepcid. also receving solumedrol 250mg q6hrs. chemo nurse administered 2 test doses of rituximab. response: pt. had no reaction to test doses. pt. started on ritimbux infusion. ritimbux 600mg in 500mls to run at 30cc/hr. dose went up at 1330. plan: monitor vital signs and for adverse reaction. adr kit at bedside. administer ritimbux per protocol.",1
252,"chief complaint: 24 hour events: - extubated patient - lenis showed - deep vein thrombosis identified in the right popliteal vein - uelis negative - mri brain -> findings suggestive of dural-based metastatic disease bifrontally, right greater than left, which may invade the anterior aspect of the sagittal sinus. there is an extra-axial lesion in the left frontal lobe which may represent metastatic disease or meningioma. no evidence of hemorrhage. - cardiac echo - ef 30%, the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is top normal/borderline dilated. no masses or thrombi are seen in the left ventricle. overall left ventricular systolic function is moderately depressed (lvef= 30 %) with inferior, infero-lateral and apical akinesis. there is no ventricular septal defect. with mild global free wall hypokinesis. the ascending aorta is mildly dilated. 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. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. - resumed regular diet, no need for tube feeds since extubated - will discuss goals of care with patient since she has capacity, ask her re anticoagulation vs filter placement allergies: penicillins rash; codeine nausea/vomiting last dose of antibiotics: vancomycin - [**2157-1-31**] 04:30 am cefipime - [**2157-2-1**] 02:12 am infusions: heparin sodium - 700 units/hour other icu medications: pantoprazole (protonix) - [**2157-2-1**] 06:15 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2157-2-1**] 06:53 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.8 c (98.3 tcurrent: 36 c (96.8 hr: 95 (56 - 109) bpm bp: 118/61(81) {95/36(56) - 139/81(104)} mmhg rr: 20 (13 - 25) insp/min spo2: 98% heart rhythm: sr (sinus rhythm) cvp: 7 (6 - 7)mmhg total in: 8,355 ml 927 ml po: tf: ivf: 5,355 ml 927 ml blood products: total out: 430 ml 150 ml urine: 430 ml 150 ml ng: stool: drains: balance: 7,925 ml 777 ml respiratory support o2 delivery device: nasal cannula ventilator mode: cpap/psv vt (spontaneous): 427 (415 - 427) ml ps : 8 cmh2o rr (spontaneous): 20 peep: 5 cmh2o fio2: 40% pip: 14 cmh2o spo2: 98% abg: 7.34/31/82.[**numeric identifier 143**]/18/-7 ve: 9.6 l/min physical examination general: nad, tired, extubated heent: pupils are equal, round, and reactive to light. mm dry lungs: clear to ausculation bilaterally, no w/r heart: regular, prominent p2, no apprec murmur abdomen: soft, mildly distended, nabs, nttp, no rebound extremities: cool, distal pulses +2, left hand erythematous, edematous and cool, radial pulse dopplerable neurologic: following commands, moving all 4 extremities and easily arousable labs / radiology 242 k/ul 8.1 g/dl 88 mg/dl 1.4 mg/dl 18 meq/l 3.9 meq/l 26 mg/dl 115 meq/l 141 meq/l 23.9 % 3.4 k/ul [image002.jpg] [**2157-1-31**] 03:01 am [**2157-1-31**] 10:24 am [**2157-1-31**] 10:39 am [**2157-1-31**] 05:09 pm [**2157-1-31**] 05:30 pm [**2157-1-31**] 08:47 pm [**2157-2-1**] 01:01 am [**2157-2-1**] 06:21 am wbc 5.3 3.4 hct 27.0 23.9 plt 355 242 cr 1.3 1.4 tropt 3.73 3.99 tco2 17 19 19 18 17 glucose 163 88 other labs: pt / ptt / inr:15.6/86.8/1.4, ck / ckmb / troponin-t:1111/192/3.99, alt / ast:400/541, alk phos / t bili:403/2.1, lactic acid:1.3 mmol/l, ldh:919 iu/l, ca++:7.8 mg/dl, mg++:2.4 mg/dl, po4:4.0 mg/dl assessment and plan 82 y/o f with cad s/p cabg and metastatic breast cancer who presented with fever and sob, found to have bilateral pes and now s/p vfib arrest, intubated and following commands. . # s/p pea arrest: pt with metastatic breast ca who p/w fever and found to have bilateral pes, went into vfib/pea arrest, coded and converted to sinus tach. most likely etiology for arrest was pe and cardiac strain, now with positive enzyme's consistent with nstemi/rv strain. pt was not a candidate for lysis given possible hemorrhagic mets. - continue heparin gtt goal ptt 60-80 - off of levophed - replace lytes aggressively . # acute pe/resp failure: pt presented with fever & found to have bilateral pes, subsequently developped vfib arrest. lysis contra-indicated due to hemorrhagic mets. resp status was stable until vfib arrest, now s/p intubation & sating well on ac 450/14/5/40%. given nstemi & pes, will rest on ac overnight. no acute infiltrate on post code cxr. - heparin gtt with goal ptt 60-80 - f/u echo in am - check le & rue u/s (if residual clot burden, consider ivc filter) - rsbi & ps support trial in am - place art line to follow abgs and sbps . # nstemi: pt with bilateral pes and positive cardiac enzymes most likely due to rv strain/infarct. much less likely to have had acute acs with simultaneous pes. however, pt with known cad s/p remote cabg and now with inferolateral st changes with positive ck/mb/troponins. pt was denying cp on admission and ce positive prior to code - cycle ces - continue heparin gtt - continue aspirin 325mg daily - try low dose metoprolol 12.5mg [**hospital1 7**] once weaned from pressors - hold off on statin given acute transaminitis - consider cards consult & f/u am echo . # fever: etiology unclear, though may have been due to acute pes. cxr essentially unchanged from prior, ua neg and blood cx sent. given recent chemo and neutropenia, pt received cefepime for possible neutropenic fever. now s/p code with intubation, will cover broadly empirically and plan to stop in 48hrs in all cx negative - vanc & cefepime - f/u urine/blood cx - repeat cxr in am - send sputum for cx . # elevated lfts: pt was noted to have new transaminitis and worsening of obstructive pattern prior to code. ruq u/s was negative for acute cholecystitis. this may be due to worsening liver mets, congestive hepatopathy, adverse reaction to chemo - trend lfts - holding statin for now - t/b with primary onc regarding navelbine . # metastatic breast cancer- pt with known progression of her disease on capecitabine, currently on navelbine, although recent cycle was held for neutropenia. ct head revealed new lesions concerning for hemorrhagic mets. - t/b with primary onc dr. [**first name4 (namepattern1) 1045**] [**last name (namepattern1) 4309**] in am - hold off on chemo for now . # hypertension: currently requiring levophed to maintain bps - holding home meds given hypotension peri-code . # hyperlipidemia- holding home statin given acute transaminitis . # anemia - stable anemia on chem, trend hct given gastroccult positive emesis (not coffee grounds) - maintain active type/cross. . # fen- npo overnight with ivf fluids - replete lytes prn, nutrition consult in am prn . # prophylaxis - heparin gtt, ppi, bowel regimen . # code status: full icu care nutrition: glycemic control: lines: 18 gauge - [**2157-1-31**] 12:43 am 20 gauge - [**2157-1-31**] 12:43 am multi lumen - [**2157-1-31**] 12:44 am arterial line - [**2157-1-31**] 08:30 am prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",1
253,"chief complaint: 24 hour events: - extubated patient - lenis showed - deep vein thrombosis identified in the right popliteal vein - uelis negative - mri brain -> findings suggestive of dural-based metastatic disease bifrontally, right greater than left, which may invade the anterior aspect of the sagittal sinus. there is an extra-axial lesion in the left frontal lobe which may represent metastatic disease or meningioma. no evidence of hemorrhage. - cardiac echo - ef 30%, the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is top normal/borderline dilated. no masses or thrombi are seen in the left ventricle. overall left ventricular systolic function is moderately depressed (lvef= 30 %) with inferior, infero-lateral and apical akinesis. there is no ventricular septal defect. with mild global free wall hypokinesis. the ascending aorta is mildly dilated. 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. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. - resumed regular diet, no need for tube feeds since extubated - will discuss goals of care with patient since she has capacity, ask her re anticoagulation vs filter placement allergies: penicillins rash; codeine nausea/vomiting last dose of antibiotics: vancomycin - [**2157-1-31**] 04:30 am cefipime - [**2157-2-1**] 02:12 am infusions: heparin sodium - 700 units/hour other icu medications: pantoprazole (protonix) - [**2157-2-1**] 06:15 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2157-2-1**] 06:53 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.8 c (98.3 tcurrent: 36 c (96.8 hr: 95 (56 - 109) bpm bp: 118/61(81) {95/36(56) - 139/81(104)} mmhg rr: 20 (13 - 25) insp/min spo2: 98% heart rhythm: sr (sinus rhythm) cvp: 7 (6 - 7)mmhg total in: 8,355 ml 927 ml po: tf: ivf: 5,355 ml 927 ml blood products: total out: 430 ml 150 ml urine: 430 ml 150 ml ng: stool: drains: balance: 7,925 ml 777 ml respiratory support o2 delivery device: nasal cannula ventilator mode: cpap/psv vt (spontaneous): 427 (415 - 427) ml ps : 8 cmh2o rr (spontaneous): 20 peep: 5 cmh2o fio2: 40% pip: 14 cmh2o spo2: 98% abg: 7.34/31/82.[**numeric identifier 143**]/18/-7 ve: 9.6 l/min physical examination general: nad, tired, extubated heent: pupils are equal, round, and reactive to light. mm dry lungs: clear to ausculation bilaterally, no w/r heart: regular, prominent p2, no apprec murmur abdomen: soft, mildly distended, nabs, nttp, no rebound extremities: cool, distal pulses +2, left hand erythematous, edematous and cool, radial pulse dopplerable neurologic: following commands, moving all 4 extremities and easily arousable labs / radiology 242 k/ul 8.1 g/dl 88 mg/dl 1.4 mg/dl 18 meq/l 3.9 meq/l 26 mg/dl 115 meq/l 141 meq/l 23.9 % 3.4 k/ul [image002.jpg] [**2157-1-31**] 03:01 am [**2157-1-31**] 10:24 am [**2157-1-31**] 10:39 am [**2157-1-31**] 05:09 pm [**2157-1-31**] 05:30 pm [**2157-1-31**] 08:47 pm [**2157-2-1**] 01:01 am [**2157-2-1**] 06:21 am wbc 5.3 3.4 hct 27.0 23.9 plt 355 242 cr 1.3 1.4 tropt 3.73 3.99 tco2 17 19 19 18 17 glucose 163 88 other labs: pt / ptt / inr:15.6/86.8/1.4, ck / ckmb / troponin-t:1111/192/3.99, alt / ast:400/541, alk phos / t bili:403/2.1, lactic acid:1.3 mmol/l, ldh:919 iu/l, ca++:7.8 mg/dl, mg++:2.4 mg/dl, po4:4.0 mg/dl assessment and plan 82 y/o f with cad s/p cabg and metastatic breast cancer who presented with fever and sob, found to have bilateral pes and now s/p vfib arrest, intubated and following commands. . # s/p pea arrest: pt with metastatic breast ca who p/w fever and found to have bilateral pes, went into vfib/pea arrest, coded and converted to sinus tach. most likely etiology for arrest was pe and cardiac strain, now with positive enzyme's consistent with nstemi/rv strain. pt was not a candidate for lysis given possible hemorrhagic mets. - continue heparin gtt goal ptt 60-80 - off of levophed - replace lytes aggressively . # acute pe/resp failure: pt presented with fever & found to have bilateral pes, subsequently developped vfib arrest. lysis contra-indicated due to hemorrhagic mets. resp status was stable until vfib arrest, now s/p intubation and extubation. - heparin gtt with goal ptt 60-80 - echo showed lvef 30%, rv dysfunction and pah - dvt in r popliteal . # nstemi: pt with bilateral pes and positive cardiac enzymes most likely due to rv strain/infarct. much less likely to have had acute acs with simultaneous pes. however, pt with known cad s/p remote cabg and now with inferolateral st changes with positive ck/mb/troponins. pt was denying cp on admission and ce positive prior to code - trop-t peaked at 3.99, ck-mb 192 - continue heparin gtt - continue aspirin 325mg daily - cont metoprolol 12.5mg [**hospital1 7**] once weaned from pressors - hold off on statin given acute transaminitis - echo showed lvef 30%, rv dysfunction and pah . # fever: etiology unclear, though may have been due to acute pes. cxr essentially unchanged from prior, ua neg and blood cx sent. given recent chemo and neutropenia, pt received cefepime for possible neutropenic fever. now s/p code with intubation, will cover broadly empirically and plan to stop in 48hrs if all cx negative - vanc & cefepime - f/u urine/blood cx - f/u cxr in am - send sputum for cx . # elevated lfts: pt was noted to have new transaminitis and worsening of obstructive pattern prior to code. ruq u/s was negative for acute cholecystitis. this may be due to worsening liver mets, congestive hepatopathy, adverse reaction to chemo - trend lfts - holding statin for now - t/b with primary onc regarding navelbine . # metastatic breast cancer- pt with known progression of her disease on capecitabine, currently on navelbine, although recent cycle was held for neutropenia. ct head revealed new lesions concerning for hemorrhagic mets. - d/w with primary onc dr. [**first name4 (namepattern1) 1045**] [**last name (namepattern1) 4309**], options for chemo/radiation . # hypertension: - holding home meds given hypotension peri-code . # hyperlipidemia- holding home statin given acute transaminitis . # anemia - stable anemia on chem, trend hct given gastroccult positive emesis (not coffee grounds) - maintain active type/cross. . # fen- reg diet, replete lytes prn . # prophylaxis - heparin gtt, ppi, bowel regimen . # code status: full icu care nutrition: glycemic control: lines: 18 gauge - [**2157-1-31**] 12:43 am 20 gauge - [**2157-1-31**] 12:43 am multi lumen - [**2157-1-31**] 12:44 am arterial line - [**2157-1-31**] 08:30 am prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",1
254,"pt. is a 47 year old primarly cambodian speaking woman with a history of neuromyelitis optica (ab neg) with transverse myelitis and baseline right eye blindness diagnosed 18 months ago. last admission was [**2137-11-11**] for new flare in the context of a e-coli uti. she has been treated with rituximab in the past. she now presents with worsening right sided weakness and numbness plus new left sided weakness and numbness and new urinary/bowel incontinence. pt. was taken first to [**hospital 4725**] hospital ed, then transfered to [**hospital1 19**] on [**12-23**] at which time she received rituximab infusion which she did not tolerate. she is being transfered to the micu today for rituximab desensitization. .h/o adverse drug event (adr, ade, medication toxicity) assessment: pt. denies pruritis or any signs of anaphylaxis. action: pt. continues to receive rituximab infusiioin at 30cc/hr. pt was premedicated with benadryl and pepcid prior to the infusion. also receving solumedrol 250mg q6hrs. chemo nurse administered 2 test doses of rituximab prior to rituximab infusion. response: pt. had no reaction to test doses. pt. continues to tolerate ritimbux infusion. ritimbux 600mg in 500mls to run at 30cc/hr. dose went up at 1330, to stop at 9:30am. am labs very difficult to obtain as it took 4 attempts. after labs drawn, piv in left antecub infiltrated. dr. [**last name (stitle) 5395**] from tsicu notified of need for central access as pt only with one piv now infusing her rituximab. pt had only received of last dose of solumedrol iv at 2am. plan: monitor vital signs and for adverse reaction. adr kit at bedside. administer ritimbux per protocol. per dr. [**last name (stitle) **] who spoke with neurology team, no central access at this time. restart solumedrol q6hr after rituximab finished. will need central access if looses piv.",1
255,"chief complaint: fever/bilateral pes/pea arrest hpi: 82 y/o f with pmhx of cad s/p cabg & metastatic breast cancer on navelbine who presented with fevers to 102 and dyspnea. pt reported 2 episodes of emesis at home and had loose stools in the ed. she was otherwise denying cough and chest pain . initial vs on arrival to ed: t 97.2 hr 66 bp 97/52 rr 16 sats 94% ra. pt was noted to have decreased breath sounds at right base but otherwise unremarkable exam. she received cefepime on arrival for presumed febrile neutropenia, but anc was actually 1500. due to elevated lfts, pt underwent ruq which showed cholelithiasis but no signs of acute inflammation. cxr showed rml opacity essentially unchanged from prior films. pt went to radiology for a cta which showed bilateral pes in the proximal lul, lll & rul. . pt had returned from radiology and had undergone a stool guaic with plan for heparin gtt when her son called out for help. pt was found unresponsive in a vfib arrest. cpr was initiated, she received epi and shocked. the next rhythm was pea and pt was started on amiodarone. pt was intubated during the 7min code and the following rhythm was a sinus tachycardia. of note, pt was hypotensive with sbps in 80s and levophed was started. amiodarone was stopped and bp improved to the 100-110 range. . ct head was performed and revealed new hyperdense lesions suggestive of new mets, thus decision was made to avoid lysis. of note, ekgs post code were noted to have inferolateral st depressions. at the time of signout, pt was still requiring levophed and had rij line in place. . on arrival to the floor, pt was intubated and sedated. she was reporting nausea and had some brown emesis that was gastroccult positive. patient admitted from: [**hospital1 19**] er history obtained from [**hospital 15**] medical records allergies: penicillins rash; codeine nausea/vomiting last dose of antibiotics: infusions: heparin sodium - 1,100 units/hour midazolam (versed) - 2 mg/hour other icu medications: other medications: past medical history: family history: social history: oncologic hx: diagnosed with right breast cancer in [**2139**] for which she underwent lumpectomy with axillary dissection and radiation therapy followed by 5 years of tamoxifen. she developed a local recurrence in [**11/2148**], diagnosed by biopsy of a palpable mass in the right breast. a right total mastectomy was performed on [**2148-12-27**], with pathology revealing a 3 cm tumor, grade ii, with lvi, er+ and her2- by immunoperoxidase staining. due to a positive serratus muscle margin, a re-excision of the right chest wall was performed on [**2149-2-28**]. she then began adjuvant therapy with letrozole. in [**10-27**], she was found to have extensive bony metastatic disease of the pelvis with additional involvement of the liver, pleura, and mediastinal lymph nodes. she was treated with zoledronic acid and fulvestrant followed by 15 months of liposomal doxorubicin, after which she was noted to have a rise in her cea and ca 27.29 tumor markers and increased bony pain. she began treatment with capecitabine monotherapy in [**6-28**] and has since remained clinically stable on this regimen, with an excellent performance status. of note, however, her most recent ct scan of the torso, obtained on [**2155-6-18**], demonstrated multiple new liver lesions and enlargement of the prior hepatic metastasis, involvement of multiple new foci in the skeleton with multiple new lytic and sclerotic lesions, and multiple new pathologically enlarged retroperitoneal nodes. her ca 27.29 was 266 on [**2156-8-19**], up from 138 on [**2156-6-18**]; cea was 4.1, down from 4.6. she received capecitabine throughout [**2155**], and is now s/p 4 cycles of navelbine, most recently in late [**2156-12-23**]. . additional medical history: 1. s/p cataract surgery [**12-27**] 2. atherosclerotic coronary vascular disease - s/p cabg in ([**2137**]) w/ no episodes of cp since 3. hypertension 4. tophaceous gout 5. hyperlipidemia 6. history of tubular adenoma nc occupation: drugs: tobacco: alcohol: other: pt is a widow who lives alone in [**location (un) 5629**], [**doctor last name 5548**]. she denies smoking. drinks 2-3 glasses of wine or beer daily. she has 6 children and 10 grandchildren. review of systems: flowsheet data as of [**2157-1-31**] 02:20 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.5 c (97.7 tcurrent: 36.5 c (97.7 hr: 74 (74 - 75) bpm bp: 109/69(79) {109/69(79) - 109/69(79)} mmhg rr: 20 (18 - 20) insp/min spo2: 98% heart rhythm: sr (sinus rhythm) total in: 13 ml po: tf: ivf: 13 ml blood products: total out: 0 ml 0 ml urine: ng: stool: drains: balance: 0 ml 13 ml respiratory o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 450 (450 - 450) ml rr (set): 14 rr (spontaneous): 0 peep: 5 cmh2o fio2: 60% pip: 16 cmh2o spo2: 98% ve: 10.2 l/min physical examination vital signs: t 97.7 hr 70 bp 100/66 rr 15 sats 100% general: nad, tired, intubated heent: pupils are equal, round, and reactive to light. mm dry lungs: clear to ausculation bilaterally, no w/r heart: regular, prominent p2, no apprec murmur abdomen: soft, mildly distended, nabs, nttp, no rebound extremities: cool, distal pulses +2, left hand erythematous, edematous and cool, radial pulse dopplerable neurologic: following commands, moving all 4 extremities and easily arousable labs / radiology [image002.jpg] fluid analysis / other labs: 141 106 25 103 agap=16 ------------- 3.8 23 1.4 . ck: 1211 mb: 165 mbi: 13.6 trop-t: 1.91 . ca: 8.4 mg: 2.0 p: 3.4 . alt: 275 ap: 528 tbili: 2.4 alb: 3.4 ast: 400 lip: 30 . wbc 3.0 d hgb 10.2 hct 29.9 plts 298 n:56.3 l:35.3 m:7.6 e:0.4 bas:0.4 . pt: 14.5 ptt: 27.9 inr: 1.3 imaging: ruq us [**2157-1-30**]: cholelithiasis, no signs of acute cholecystitis. known liver mets, largest 7.2 x 4.6 cm. no ductal dilatation. . cxr [**2157-1-30**] portable: ett 4.5 cm from carina. ngt below diaphragm. no new parenchymal abnormalities in the lungs. no change in scarring vs consolidation at the medial right middle lobe. no effusions. . cta: prelim read: acute pe's involving proximal lul, lll, and rul. no ct signs of rv strain. new small rt effusion. worsened peripheral right sided opacities may reflect worsening lymphagetic spread of dz, regions of early infarction or superimposed infection. . ct head [**2157-1-30**]: new hyperdense lesions along the anterior falx and left frontal lobe, differential broad but includes meningioma and hemmorrhagic metastatic disease. diffuse osseous mets . microbiology: blood cx x 2 pending ecg: ekg 8pm [**2157-1-30**]: nsr with 1mm st depression and twi in ii, iii, avf, v3 through v6. assessment and plan 82 y/o f with cad s/p cabg and metastatic breast cancer who presented with fever and sob, found to have bilateral pes and now s/p vfib arrest, intubated and following commands. . # s/p pea arrest: pt with metastatic breast ca who p/w fever and found to have bilateral pes, went into vfib/pea arrest, coded and converted to sinus tach. most likely etiology for arrest was pe and cardiac strain, now with positive enzyme's consistent with nstemi. pt not a candidate for lysis given possible hemorrhagic mets - continue heparin gtt goal ptt 60-80 - levophed to maintain maps - intubated on ac - pacer pads in place - replace lytes aggressively - place art line prn . # acute pe/resp failure: pt presented with fever & found to have bilateral pes, subsequently developped vfib arrest. lysis contra-indicated due to hemorrhagic mets. resp status was stable until vfib arrest, now s/p intubation & sating well on ac 450/14/5/40%. given nstemi & pes, will rest on ac overnight. no acute infiltrate on post code cxr. - heparin gtt with goal ptt 60-80 - f/u echo in am - check le & rue u/s (if residual clot burden, consider ivc filter) - rsbi & ps support trial in am - place art line to follow abgs and sbps . # nstemi: pt with bilateral pes and positive cardiac enzymes most likely due to rv strain/infarct. much less likely to have had acute acs with simultaneous pes. however, pt with known cad s/p remote cabg and now with inferolateral st changes with positive ck/mb/troponins. pt was denying cp on admission and ce positive prior to code - cycle ces - continue heparin gtt - continue aspirin 325mg daily - try low dose metoprolol 12.5mg [**hospital1 7**] once weaned from pressors - hold off on statin given acute transaminitis - consider cards consult & f/u am echo . # fever: etiology unclear, though may have been due to acute pes. cxr essentially unchanged from prior, ua neg and blood cx sent. given recent chemo and neutropenia, pt received cefepime for possible neutropenic fever. now s/p code with intubation, will cover broadly empirically and plan to stop in 48hrs in all cx negative - vanc & cefepime - f/u urine/blood cx - repeat cxr in am - send sputum for cx . # elevated lfts: pt was noted to have new transaminitis and worsening of obstructive pattern prior to code. ruq u/s was negative for acute cholecystitis. this may be due to worsening liver mets, congestive hepatopathy, adverse reaction to chemo - trend lfts - holding statin for now - t/b with primary onc regarding navelbine . # metastatic breast cancer- pt with known progression of her disease on capecitabine, currently on navelbine, although recent cycle was held for neutropenia. ct head revealed new lesions concerning for hemorrhagic mets. - t/b with primary onc dr. [**first name4 (namepattern1) 1045**] [**last name (namepattern1) 4309**] in am - hold off on chemo for now . # hypertension: currently requiring levophed to maintain bps - holding home meds given hypotension peri-code . # hyperlipidemia- holding home statin given acute transaminitis . # anemia - stable anemia on chem, trend hct given gastroccult positive emesis (not coffee grounds) - maintain active type/cross. . # fen- npo overnight with ivf fluids - replete lytes prn, nutrition consult in am prn . # prophylaxis - heparin gtt, ppi, bowel regimen . # code status: full icu care nutrition: npo for now, nutrition consult for tfs prn glycemic control: none lines: 18 gauge - [**2157-1-31**] 12:43 am 20 gauge - [**2157-1-31**] 12:43 am multi lumen - [**2157-1-31**] 12:44 am prophylaxis: dvt: heparin gtt stress ulcer: ppi vap: hob elevation, mouth care, daily wake up, rsbi communication: with patient and hcp [**name (ni) **] [**name (ni) **] [**known lastname **] code status: full code disposition: icu ------ protected section ------ attending addendum: i saw and examined the patient, and was physically present with the icu resident for my examination. i agree with his / her note above, including assessment and plan and medical histories. please see my comments on note dated [**1-31**]. ------ protected section addendum entered by:[**name (ni) 457**] [**last name (namepattern1) **], md on:[**2157-1-31**] 08:48 ------",1
256,"pt. is a 47 year old primarly cambodian speaking woman with a history of neuromyelitis optica (ab neg) with transverse myelitis and baseline right eye blindness diagnosed 18 months ago. last admission was [**2137-11-11**] for new flare in the context of a e-coli uti. she has been treated with rituximab in the past. she now presents with worsening right sided weakness and numbness plus new left sided weakness and numbness and new urinary/bowel incontinence. pt. was taken first to [**hospital 4725**] hospital ed, then transfered to [**hospital1 19**] on [**12-23**] at which time she received rituximab infusion which she did not tolerate. she is being transfered to the micu today (tsicu border) for rituximab desensitization. .h/o adverse drug event (adr, ade, medication toxicity) assessment: pt. denies pruritis or any signs of anaphylaxis. action: pt. finished receiving rituximab infusion at 30cc/hr. pt was premedicated with benadryl and pepcid prior to the infusion. also receving solumedrol 250mg q6hrs. chemo nurse administered 2 test doses of rituximab prior to rituximab infusion. response: pt. had no outward s&s of reaction to rituximab. plan: cont. to monitor for s&s of adverse reaction. supportive care as needed. demographics attending md: [**first name9 (namepattern2) 5422**] [**doctor first name 5423**] admit diagnosis: le weakness code status: full code height: admission weight: 67.7 kg daily weight: allergies/reactions: penicillins unknown; biaxin (oral) (clarithromycin) unknown; levaquin (oral) (levofloxacin) hepatic toxicit precautions: no additional precautions pmh: diabetes - insulin, hepatitis cv-pmh: additional history: neuromyelitis optica, nmo titer negative, hbv core and surface antibody positive, surface antigen negative, gerd, dm, s/p hysterectomy surgery / procedure and date: latest vital signs and i/o non-invasive bp: s:91 d:50 temperature: 96.3 arterial bp: s: d: respiratory rate: 15 insp/min heart rate: 84 bpm heart rhythm: sr (sinus rhythm) o2 delivery device: none o2 saturation: 92% % o2 flow: fio2 set: 24h total in: 606 ml 24h total out: 1,520 ml pertinent lab results: sodium: 140 meq/l [**2138-1-3**] 03:39 am potassium: 4.1 meq/l [**2138-1-3**] 03:39 am chloride: 108 meq/l [**2138-1-3**] 03:39 am co2: 25 meq/l [**2138-1-3**] 03:39 am bun: 15 mg/dl [**2138-1-3**] 03:39 am creatinine: 0.4 mg/dl [**2138-1-3**] 03:39 am glucose: 136 mg/dl [**2138-1-3**] 03:39 am hematocrit: 35.2 % [**2138-1-3**] 03:39 am finger stick glucose: 237 [**2138-1-3**] 09:00 am valuables / signature patient valuables: other valuables: clothes: sent home with: wallet / money: no money / wallet cash / credit cards sent home with: jewelry: transferred from: transferred to: date & time of transfer:",1
257,"chief complaint: fever/bilateral pes/pea arrest hpi: 82 y/o f with pmhx of cad s/p cabg & metastatic breast cancer on navelbine who presented with fevers to 102 and dyspnea. pt reported 2 episodes of emesis at home and had loose stools in the ed. she was otherwise denying cough and chest pain . initial vs on arrival to ed: t 97.2 hr 66 bp 97/52 rr 16 sats 94% ra. pt was noted to have decreased breath sounds at right base but otherwise unremarkable exam. she received cefepime on arrival for presumed febrile neutropenia, but anc was actually 1500. due to elevated lfts, pt underwent ruq which showed cholelithiasis but no signs of acute inflammation. cxr showed rml opacity essentially unchanged from prior films. pt went to radiology for a cta which showed bilateral pes in the proximal lul, lll & rul. . pt had returned from radiology and had undergone a stool guaic with plan for heparin gtt when her son called out for help. pt was found unresponsive in a vfib arrest. cpr was initiated, she received epi and shocked. the next rhythm was pea and pt was started on amiodarone. pt was intubated during the 7min code and the following rhythm was a sinus tachycardia. of note, pt was hypotensive with sbps in 80s and levophed was started. amiodarone was stopped and bp improved to the 100-110 range. . ct head was performed and revealed new hyperdense lesions suggestive of new mets, thus decision was made to avoid lysis. of note, ekgs post code were noted to have inferolateral st depressions. at the time of signout, pt was still requiring levophed and had rij line in place. . on arrival to the floor, pt was intubated and sedated. she was reporting nausea and had some brown emesis that was gastroccult positive. patient admitted from: [**hospital1 19**] er history obtained from [**hospital 15**] medical records allergies: penicillins rash; codeine nausea/vomiting last dose of antibiotics: infusions: heparin sodium - 1,100 units/hour midazolam (versed) - 2 mg/hour other icu medications: other medications: past medical history: family history: social history: oncologic hx: diagnosed with right breast cancer in [**2139**] for which she underwent lumpectomy with axillary dissection and radiation therapy followed by 5 years of tamoxifen. she developed a local recurrence in [**11/2148**], diagnosed by biopsy of a palpable mass in the right breast. a right total mastectomy was performed on [**2148-12-27**], with pathology revealing a 3 cm tumor, grade ii, with lvi, er+ and her2- by immunoperoxidase staining. due to a positive serratus muscle margin, a re-excision of the right chest wall was performed on [**2149-2-28**]. she then began adjuvant therapy with letrozole. in [**10-27**], she was found to have extensive bony metastatic disease of the pelvis with additional involvement of the liver, pleura, and mediastinal lymph nodes. she was treated with zoledronic acid and fulvestrant followed by 15 months of liposomal doxorubicin, after which she was noted to have a rise in her cea and ca 27.29 tumor markers and increased bony pain. she began treatment with capecitabine monotherapy in [**6-28**] and has since remained clinically stable on this regimen, with an excellent performance status. of note, however, her most recent ct scan of the torso, obtained on [**2155-6-18**], demonstrated multiple new liver lesions and enlargement of the prior hepatic metastasis, involvement of multiple new foci in the skeleton with multiple new lytic and sclerotic lesions, and multiple new pathologically enlarged retroperitoneal nodes. her ca 27.29 was 266 on [**2156-8-19**], up from 138 on [**2156-6-18**]; cea was 4.1, down from 4.6. she received capecitabine throughout [**2155**], and is now s/p 4 cycles of navelbine, most recently in late [**2156-12-23**]. . additional medical history: 1. s/p cataract surgery [**12-27**] 2. atherosclerotic coronary vascular disease - s/p cabg in ([**2137**]) w/ no episodes of cp since 3. hypertension 4. tophaceous gout 5. hyperlipidemia 6. history of tubular adenoma nc occupation: drugs: tobacco: alcohol: other: pt is a widow who lives alone in [**location (un) 5629**], [**doctor last name 5548**]. she denies smoking. drinks 2-3 glasses of wine or beer daily. she has 6 children and 10 grandchildren. review of systems: flowsheet data as of [**2157-1-31**] 02:20 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.5 c (97.7 tcurrent: 36.5 c (97.7 hr: 74 (74 - 75) bpm bp: 109/69(79) {109/69(79) - 109/69(79)} mmhg rr: 20 (18 - 20) insp/min spo2: 98% heart rhythm: sr (sinus rhythm) total in: 13 ml po: tf: ivf: 13 ml blood products: total out: 0 ml 0 ml urine: ng: stool: drains: balance: 0 ml 13 ml respiratory o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 450 (450 - 450) ml rr (set): 14 rr (spontaneous): 0 peep: 5 cmh2o fio2: 60% pip: 16 cmh2o spo2: 98% ve: 10.2 l/min physical examination vital signs: t 97.7 hr 70 bp 100/66 rr 15 sats 100% general: nad, tired, intubated heent: pupils are equal, round, and reactive to light. mm dry lungs: clear to ausculation bilaterally, no w/r heart: regular, prominent p2, no apprec murmur abdomen: soft, mildly distended, nabs, nttp, no rebound extremities: cool, distal pulses +2, left hand erythematous, edematous and cool, radial pulse dopplerable neurologic: following commands, moving all 4 extremities and easily arousable labs / radiology [image002.jpg] fluid analysis / other labs: 141 106 25 103 agap=16 ------------- 3.8 23 1.4 . ck: 1211 mb: 165 mbi: 13.6 trop-t: 1.91 . ca: 8.4 mg: 2.0 p: 3.4 . alt: 275 ap: 528 tbili: 2.4 alb: 3.4 ast: 400 lip: 30 . wbc 3.0 d hgb 10.2 hct 29.9 plts 298 n:56.3 l:35.3 m:7.6 e:0.4 bas:0.4 . pt: 14.5 ptt: 27.9 inr: 1.3 imaging: ruq us [**2157-1-30**]: cholelithiasis, no signs of acute cholecystitis. known liver mets, largest 7.2 x 4.6 cm. no ductal dilatation. . cxr [**2157-1-30**] portable: ett 4.5 cm from carina. ngt below diaphragm. no new parenchymal abnormalities in the lungs. no change in scarring vs consolidation at the medial right middle lobe. no effusions. . cta: prelim read: acute pe's involving proximal lul, lll, and rul. no ct signs of rv strain. new small rt effusion. worsened peripheral right sided opacities may reflect worsening lymphagetic spread of dz, regions of early infarction or superimposed infection. . ct head [**2157-1-30**]: new hyperdense lesions along the anterior falx and left frontal lobe, differential broad but includes meningioma and hemmorrhagic metastatic disease. diffuse osseous mets . microbiology: blood cx x 2 pending ecg: ekg 8pm [**2157-1-30**]: nsr with 1mm st depression and twi in ii, iii, avf, v3 through v6. assessment and plan 82 y/o f with cad s/p cabg and metastatic breast cancer who presented with fever and sob, found to have bilateral pes and now s/p vfib arrest, intubated and following commands. . # s/p pea arrest: pt with metastatic breast ca who p/w fever and found to have bilateral pes, went into vfib/pea arrest, coded and converted to sinus tach. most likely etiology for arrest was pe and cardiac strain, now with positive enzyme's consistent with nstemi. pt not a candidate for lysis given possible hemorrhagic mets - continue heparin gtt goal ptt 60-80 - levophed to maintain maps - intubated on ac - pacer pads in place - replace lytes aggressively - place art line prn . # acute pe/resp failure: pt presented with fever & found to have bilateral pes, subsequently developped vfib arrest. lysis contra-indicated due to hemorrhagic mets. resp status was stable until vfib arrest, now s/p intubation & sating well on ac 450/14/5/40%. given nstemi & pes, will rest on ac overnight. no acute infiltrate on post code cxr. - heparin gtt with goal ptt 60-80 - f/u echo in am - check le & rue u/s (if residual clot burden, consider ivc filter) - rsbi & ps support trial in am - place art line to follow abgs and sbps . # nstemi: pt with bilateral pes and positive cardiac enzymes most likely due to rv strain/infarct. much less likely to have had acute acs with simultaneous pes. however, pt with known cad s/p remote cabg and now with inferolateral st changes with positive ck/mb/troponins. pt was denying cp on admission and ce positive prior to code - cycle ces - continue heparin gtt - continue aspirin 325mg daily - try low dose metoprolol 12.5mg [**hospital1 7**] once weaned from pressors - hold off on statin given acute transaminitis - consider cards consult & f/u am echo . # fever: etiology unclear, though may have been due to acute pes. cxr essentially unchanged from prior, ua neg and blood cx sent. given recent chemo and neutropenia, pt received cefepime for possible neutropenic fever. now s/p code with intubation, will cover broadly empirically and plan to stop in 48hrs in all cx negative - vanc & cefepime - f/u urine/blood cx - repeat cxr in am - send sputum for cx . # elevated lfts: pt was noted to have new transaminitis and worsening of obstructive pattern prior to code. ruq u/s was negative for acute cholecystitis. this may be due to worsening liver mets, congestive hepatopathy, adverse reaction to chemo - trend lfts - holding statin for now - t/b with primary onc regarding navelbine . # metastatic breast cancer- pt with known progression of her disease on capecitabine, currently on navelbine, although recent cycle was held for neutropenia. ct head revealed new lesions concerning for hemorrhagic mets. - t/b with primary onc dr. [**first name4 (namepattern1) 1045**] [**last name (namepattern1) 4309**] in am - hold off on chemo for now . # hypertension: currently requiring levophed to maintain bps - holding home meds given hypotension peri-code . # hyperlipidemia- holding home statin given acute transaminitis . # anemia - stable anemia on chem, trend hct given gastroccult positive emesis (not coffee grounds) - maintain active type/cross. . # fen- npo overnight with ivf fluids - replete lytes prn, nutrition consult in am prn . # prophylaxis - heparin gtt, ppi, bowel regimen . # code status: full icu care nutrition: npo for now, nutrition consult for tfs prn glycemic control: none lines: 18 gauge - [**2157-1-31**] 12:43 am 20 gauge - [**2157-1-31**] 12:43 am multi lumen - [**2157-1-31**] 12:44 am prophylaxis: dvt: heparin gtt stress ulcer: ppi vap: hob elevation, mouth care, daily wake up, rsbi communication: with patient and hcp [**name (ni) **] [**name (ni) **] [**known lastname **] code status: full code disposition: icu",1
258,"chief complaint: 24 hour events: sheath - start [**2105-3-13**] 08:22 pm note sheath started in other hospital arterial sheath - stop [**2105-3-13**] 08:34 pm note sheath started in other hospital arterial tolerated asa desensitization given lasix 40 iv this am and last night with good uop, negative 1.5 liters since arrival allergies: penicillins rash; aspirin wheezing; last dose of antibiotics: infusions: other icu medications: furosemide (lasix) - [**2105-3-14**] 12:08 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2105-3-14**] 05:54 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.2 c (98.9 tcurrent: 37.2 c (98.9 hr: 100 (97 - 107) bpm bp: 100/56(48) {87/35(48) - 112/72(103)} mmhg rr: 20 (18 - 33) insp/min spo2: 100% heart rhythm: st (sinus tachycardia) total in: 200 ml po: 200 ml tf: ivf: blood products: total out: 880 ml 955 ml urine: 880 ml 955 ml ng: stool: drains: balance: -880 ml -755 ml respiratory support o2 delivery device: nasal cannula spo2: 100% abg: ///29/ physical examination vs - t 98.2, hr 105, bp 109/47, rr 22, 100% on 3l nc gen: wdwn middle aged female in nad. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 10 cm. cv: pmi laterally displaced. rrr. [**3-13**] holosystoli blowingm urmur radiating to apex. normal s1, s2. chest: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. pt occasioannly tachypneic with anxiety. crackles in bases anteriorly. abd: soft, nt. moderately distended with + bs. hepatomegaly 2-3cm below costal margin but no tenderness. abd aorta not enlarged by palpation. no abdominal bruits. ext: no c/c/e. no femoral bruits. r femoral dsg cdi. skin: no stasis dermatitis, ulcers, scars, or xanthomas. . pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ labs / radiology 302 k/ul 12.7 g/dl 167 mg/dl 1.0 mg/dl 29 meq/l 4.9 meq/l 18 mg/dl 96 meq/l 134 meq/l 38.6 % 10.4 k/ul [image002.jpg] [**2105-3-13**] 07:28 pm [**2105-3-14**] 03:15 am wbc 12.2 10.4 hct 37.6 38.6 plt 335 302 cr 1.0 tropt 0.10 glucose 167 other labs: pt / ptt / inr:15.8/28.4/1.4, ck / ckmb / troponin-t:120/4/0.10, alt / ast:65/40, alk phos / t bili:59/0.4, amylase / lipase:26/27, albumin:4.0 g/dl, ldh:311 iu/l, ca++:8.9 mg/dl, mg++:2.7 mg/dl, po4:3.5 mg/dl assessment and plan assessment and plan, as reviewed and discussed in multidisciplinary rounds patient is a 59f with nonischemic dilated cardiomyopathy admitted with progressive sob and intermittent cp with elevated biomarkers at osh, 2vd with 80 on cath transferred for asa desensitization and pci . #. asa desensitization: will perform asa desensitization per protocol. if asthma, adverse reaction more likely to occur at higher doses. anaphylaxis more likely to occur immediately at lower doses - tolerated well . #. cad/chest pain: pt found to have 2vd on cardiac cath. echo without focal wma so unclear if 2vd is true etiology of symptoms although per her report this lesions is new compared with [**2102**] so may be possible contributing factor. trop i and ck elevated at osh but only slightly above upper limit normal and may be consistent with strain and heart failure exacerbation. ekg changes could also be c/w strain. [**month (only) 51**] benefit from revascularization, specifically rca lesion 70-80%. - continue plavix - comepleted asa desensitization per protocol, will now continue asa 325 daily - check biomarkers here and trend . #. pump: pt with non ischemic dilated cm of unknown etiology ef 20-25% with severe global hk. symptoms over last several months most c/w worsening decompensated systolic heart failure. possible exacerbating factors include dietary indiscretion and recent viral illness, increased demand or progressive worsening of rca lesion. on exam today still appears volume overloaded. no focal wma abnormalities to suggest acute ischemic event as cause. per notes, she is not candidate for heart transplant [**2-9**] pulm htn and has refused icd in past. per osh records had elevated dig level recently so this was held. bnp elevated - continue lasix iv prn. gave 40 iv x2 and negative 1600cc since arrival. goal negative 1.5 liters per day - f/u cxr in am - holding dig; check dig level - continue aldactone, restart ace - continue bb, consider change to carvedilol . #. rhythm: sinus tach overnight. currently nsr. - continue beta blocker although will monitor since can worsen bronchospasm; consider change to carvedilol given hf . #abd distension: likely [**2-9**] chf and volume overload. lfts, amylase, lipase normal. consider ultrasound if no improvement with diuresis. . #. asthma: pt has h/o increased bronchospasm with asa in past. will continue outpt regimen and received iv solumedrol prior to asa. - continue advair - continue home prednisone 5mg daily - albuterol nebs prn . #. anxiety/depression: continue celexa, valium, buspar . #. hypothyrodism: continue synthroid, check tsh . #. fen: cardiac heart healthy low sodium , npo after mn on sunday evening . #. access: piv . #. ppx: hep sc, ppi, bowel regimen . #. code: full . #. dispo: pending above . . icu care nutrition: glycemic control: lines: 20 gauge - [**2105-3-13**] 08:15 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",1
259,"chief complaint: asa desensitization prior to cath hpi: this is a 59 year-old female with a history of non ischemic dilated cardiomyopathy ef 20-25% followed by [**hospital **] clinic at [**hospital1 1030**] who was admitted to nebh 3/309 with progressively worsening sob since [**month (only) **] [**2104**], diaphoresis and chest pain. she was found to be in heart failure with elevated bnp and ruled in for nstemi with troponin i 5.97 peak, ck 212, ckmb 5.1 index 2.4. she was diuresed, started on nitro gtt and heparin gtt and underwent cardiac cath [**2105-3-13**] with 2vd with 50% proximal and 50% mid lad stenosis as well as 70-80% stenosis distal rca. heparin gtt d/c'd at 0800. due to reaction of anaphylaxis with asa she was transferred here for asa desensitization and pci. she report continued sob and diaphoresis which has been present since [**month (only) 3**] and was precipitaed by flu like illness. she denies any current chest pain buit has had intermittent epigastric discomfort typically relieved with maalox. she reports exertional dyspnea, pnd, orthopnea. denies presyncope, syncope, or palpitations. . echo at osh: lv markedly dilated, severe global hk, ef 20-25%, [**name prefix (prefixes) **] [**last name (prefixes) 3870**] dilated, rv mildly enlarged, rv fxn mildly impaired, ra mildly enlarged, moderate mr, mild-mod tr, small left pleural effusion. . on arrival, reports diaphoresis, sob. denies cp, palpitations. patient admitted from: transfer from other hospital history obtained from [**hospital 15**] medical records allergies: penicillins rash; aspirin wheezing; last dose of antibiotics: infusions: other icu medications: furosemide (lasix) - [**2105-3-14**] 12:08 am other medications: isosorbide 30mg po bid enalapril 20mg po bid spironolactone 25mg daily lasix 80mg [**hospital1 7**] toprol xl 12.5mg daily digoxin 0.125 mg daily buspar 30mg [**hospital1 **] albuterol 2 puffs qid prn citracal d 2 tabs po bid prednisone 5mg daily levoxyl 50mcg daily lipitor 10mg daily effexor xr 300mg daily diazepam 5mg prn estradiol topical advair 250/50 [**hospital1 7**] prevacid 30mg daily colace 1 capsule [**hospital1 7**] temazepam 15mg qhs valium 5mg tid past medical history: family history: social history: non ischemic cardiomyopathy ef 20-25% diagnosed 14 years ago asthma htn mitral valve regurgitation sleep apnea pulmonary htn hypothyroidism depression/anxiety . percutaneous coronary intervention, in [**2105-3-13**] anatomy as follows: left main normal lad gives rise to mod diag, 50% prox and mid 50% mid lad stenosis left circ 30% ostila stenosis rca dominant. 70-80% stenosis distal rca. run off very good there is no history of alcohol abuse. there is no family history of premature coronary artery disease or sudden death. occupation: drugs: tobacco: alcohol: other: patient is single. works part time at library. social history is significant for the absence of current tobacco use review of systems: constitutional: fatigue, fever cardiovascular: chest pain, palpitations, edema, orthopnea respiratory: cough, dyspnea, tachypnea, wheeze gastrointestinal: abdominal pain, nausea, emesis, no(t) diarrhea, no(t) constipation genitourinary: no(t) dysuria, foley musculoskeletal: myalgias neurologic: no(t) numbness / tingling, no(t) headache flowsheet data as of [**2105-3-14**] 12:50 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.8 c (98.2 tcurrent: 36.6 c (97.9 hr: 106 (101 - 107) bpm bp: 100/58(103) {87/35(49) - 112/72(103)} mmhg rr: 28 (18 - 31) insp/min spo2: 98% heart rhythm: st (sinus tachycardia) total in: po: tf: ivf: blood products: total out: 880 ml 175 ml urine: 880 ml 175 ml ng: stool: drains: balance: -880 ml -175 ml respiratory o2 delivery device: nasal cannula spo2: 98% abg: ///29/ physical examination vs - t 98.2, hr 105, bp 109/47, rr 22, 100% on 3l nc gen: wdwn middle aged female in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 10 cm. cv: pmi laterally displaced. tachy. reg. [**3-13**] holosystoli blowing urmur radiating to apex. normal s1, s2. chest: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. pt occasioannly tachypneic with anxiety. crackles in bases anteriorly. abd: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. ext: no c/c/e. no femoral bruits. r femoral dsg cdi. ext slightly mottled skin: no stasis dermatitis, ulcers, scars, or xanthomas. . pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ labs / radiology 335 k/ul 12.4 g/dl 167 mg/dl 1.0 mg/dl 18 mg/dl 29 meq/l 96 meq/l 4.9 meq/l 134 meq/l 37.6 % 12.2 k/ul [image002.jpg] [**2102-1-9**] 2:33 a3/6/[**2105**] 07:28 pm [**2102-1-13**] 10:20 p [**2102-1-14**] 1:20 p [**2102-1-15**] 11:50 p [**2102-1-16**] 1:20 a [**2102-1-17**] 7:20 p 1//11/006 1:23 p [**2102-2-9**] 1:20 p [**2102-2-9**] 11:20 p [**2102-2-9**] 4:20 p wbc 12.2 hct 37.6 plt 335 cr 1.0 tropt 0.10 glucose 167 other labs: pt / ptt / inr:15.4/29.0/1.4, ck / ckmb / troponin-t:120/4/0.10, alt / ast:65/40, alk phos / t bili:59/0.4, amylase / lipase:26/27, albumin:4.0 g/dl, ldh:311 iu/l, ca++:8.9 mg/dl, mg++:2.7 mg/dl, po4:3.5 mg/dl ekg demonstrated nsr. normal axis. lvh with strain pattern with downsloping st depressions v5-v6 with twi. unchanged from prior [**2105-3-12**]. telemetry demonstrated:pending 2d-echocardiogram performed on [**2105-3-12**] demonstrated: as above cardiac cath performed on [**2105-3-13**] demonstrated: as above assessment and plan assessment and plan, as reviewed and discussed in multidisciplinary rounds patient is a 59f with nonischemic dilated cardiomyopathy admitted with progressive sob and intermittent cp with borderline elevated biomarkers at osh transferred for asa desensitization . #. asa desensitization: will perform asa desensitization per protocol. if asthma, adverse reaction more likely to occur at higher doses. anaphylaxis more likely to occur immediately at lower doses - asa desensitization protocol adjusted so 2-3 hour gap between steps 9 and 10 (162 and 325 mg) - singulair prior to asa administration - epi sc at bedside - benadryl, solummedrol prior to asa . #. cad/chest pain: pt found to have 2vd on cardiac cath. echo without focal wma so unclear if 2vd is true etiology of symptoms. trop i and ck elevated at osh but only slightly above upper limit normal and may be consistent with strain and heart failure exacerbation. ekg changes could also be c/w strain. [**month (only) 51**] benefit from revascularization, however, with 2vd, specifically rca lesion 70-80%. - continue plavix - asa desensitization per protocol - check biomarkers here and trend - check lfts, amylase, lipase since pain more epigastric in nature . #. pump: pt with non ischemic dilated cm of unknown etiology ef 20-25% with severe global hk. symptoms over last several months most c/w worsening decompensated systolic heart failure. possible exacerbatng factors include dietary indiscretion and recent viral illness, increased demand. on exam today still appears volume overloaded. no focal wma abnormalities to suggest ischemic event as cause. per notes, is not candidate for heart transplant [**2-9**] pulm htn and has refused icd in past. per osh records had elevated dig level. - continue lasix iv prn. gave 40 iv on arrival to assess response and will repeat prn. goal negative 1-1.5 liters per day - cxr in am - bnp for baseline - holding dig; check dig level - continue aldactone - hold ace [**2-9**] increased risk anaphylaxis and angioedema - continue bb . #. rhythm: sinus tach currently - continue beta blocker although will monitor since can worsen bronchospasm; consider change to carvedilol . #. asthma: pt has h/o increased bronchospasm with asa in past. will continue outpt regimen with solumedrol prior to asa - iv solumedrol prior to asa - continue advair - singulair prior to asa - albuterol nebs prn . #. anxiety/depression: continue celexa, valium, buspar . #. hypothyrodism: continue synthroid . #. fen: cardiac heart healthy low sodium . #. access: piv . #. ppx: hep sc, ppi, bowel regimen . #. code: full . #. dispo: pending above . . icu care nutrition: glycemic control: lines: 20 gauge - [**2105-3-13**] 08:15 pm prophylaxis: dvt: sq uf heparin stress ulcer: vap: comments: communication: patient discussed on interdisciplinary rounds comments: code status: full code disposition: icu",1
260,"chief complaint: asa desensitization prior to cath hpi: this is a 59 year-old female with a history of non ischemic dilated cardiomyopathy ef 20-25% followed by [**hospital **] clinic at [**hospital1 1030**] who was admitted to nebh 3/309 with progressively worsening sob since [**month (only) **] [**2104**], diaphoresis and chest pain. she was found to be in heart failure with elevated bnp and ruled in for nstemi with troponin i 5.97 peak, ck 212, ckmb 5.1 index 2.4. she was diuresed, started on nitro gtt and heparin gtt and underwent cardiac cath [**2105-3-13**] with 2vd with 50% proximal and 50% mid lad stenosis as well as 70-80% stenosis distal rca. heparin gtt d/c'd at 0800. due to reaction of anaphylaxis with asa she was transferred here for asa desensitization and pci. she report continued sob and diaphoresis which has been present since [**month (only) 3**] and was precipitaed by flu like illness. she denies any current chest pain buit has had intermittent epigastric discomfort typically relieved with maalox. she reports exertional dyspnea, pnd, orthopnea. denies presyncope, syncope, or palpitations. . echo at osh: lv markedly dilated, severe global hk, ef 20-25%, [**name prefix (prefixes) **] [**last name (prefixes) 3870**] dilated, rv mildly enlarged, rv fxn mildly impaired, ra mildly enlarged, moderate mr, mild-mod tr, small left pleural effusion. . on arrival, reports diaphoresis, sob. denies cp, palpitations. patient admitted from: transfer from other hospital history obtained from [**hospital 15**] medical records allergies: penicillins rash; aspirin wheezing; last dose of antibiotics: infusions: other icu medications: furosemide (lasix) - [**2105-3-14**] 12:08 am other medications: isosorbide 30mg po bid enalapril 20mg po bid spironolactone 25mg daily lasix 80mg [**hospital1 7**] toprol xl 12.5mg daily digoxin 0.125 mg daily buspar 30mg [**hospital1 **] albuterol 2 puffs qid prn citracal d 2 tabs po bid prednisone 5mg daily levoxyl 50mcg daily lipitor 10mg daily effexor xr 300mg daily diazepam 5mg prn estradiol topical advair 250/50 [**hospital1 7**] prevacid 30mg daily colace 1 capsule [**hospital1 7**] temazepam 15mg qhs valium 5mg tid past medical history: family history: social history: non ischemic cardiomyopathy ef 20-25% diagnosed 14 years ago asthma htn mitral valve regurgitation sleep apnea pulmonary htn hypothyroidism depression/anxiety . percutaneous coronary intervention, in [**2105-3-13**] anatomy as follows: left main normal lad gives rise to mod diag, 50% prox and mid 50% mid lad stenosis left circ 30% ostila stenosis rca dominant. 70-80% stenosis distal rca. run off very good there is no history of alcohol abuse. there is no family history of premature coronary artery disease or sudden death. occupation: drugs: tobacco: alcohol: other: patient is single. works part time at library. social history is significant for the absence of current tobacco use review of systems: constitutional: fatigue, fever cardiovascular: chest pain, palpitations, edema, orthopnea respiratory: cough, dyspnea, tachypnea, wheeze gastrointestinal: abdominal pain, nausea, emesis, no(t) diarrhea, no(t) constipation genitourinary: no(t) dysuria, foley musculoskeletal: myalgias neurologic: no(t) numbness / tingling, no(t) headache flowsheet data as of [**2105-3-14**] 12:50 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.8 c (98.2 tcurrent: 36.6 c (97.9 hr: 106 (101 - 107) bpm bp: 100/58(103) {87/35(49) - 112/72(103)} mmhg rr: 28 (18 - 31) insp/min spo2: 98% heart rhythm: st (sinus tachycardia) total in: po: tf: ivf: blood products: total out: 880 ml 175 ml urine: 880 ml 175 ml ng: stool: drains: balance: -880 ml -175 ml respiratory o2 delivery device: nasal cannula spo2: 98% abg: ///29/ physical examination vs - t 98.2, hr 105, bp 109/47, rr 22, 100% on 3l nc gen: wdwn middle aged female in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 10 cm. cv: pmi laterally displaced. tachy. reg. [**3-13**] holosystoli blowing urmur radiating to apex. normal s1, s2. chest: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. pt occasioannly tachypneic with anxiety. crackles in bases anteriorly. abd: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. ext: no c/c/e. no femoral bruits. r femoral dsg cdi. ext slightly mottled skin: no stasis dermatitis, ulcers, scars, or xanthomas. . pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ labs / radiology 335 k/ul 12.4 g/dl 167 mg/dl 1.0 mg/dl 18 mg/dl 29 meq/l 96 meq/l 4.9 meq/l 134 meq/l 37.6 % 12.2 k/ul [image002.jpg] [**2102-1-9**] 2:33 a3/6/[**2105**] 07:28 pm [**2102-1-13**] 10:20 p [**2102-1-14**] 1:20 p [**2102-1-15**] 11:50 p [**2102-1-16**] 1:20 a [**2102-1-17**] 7:20 p 1//11/006 1:23 p [**2102-2-9**] 1:20 p [**2102-2-9**] 11:20 p [**2102-2-9**] 4:20 p wbc 12.2 hct 37.6 plt 335 cr 1.0 tropt 0.10 glucose 167 other labs: pt / ptt / inr:15.4/29.0/1.4, ck / ckmb / troponin-t:120/4/0.10, alt / ast:65/40, alk phos / t bili:59/0.4, amylase / lipase:26/27, albumin:4.0 g/dl, ldh:311 iu/l, ca++:8.9 mg/dl, mg++:2.7 mg/dl, po4:3.5 mg/dl ekg demonstrated nsr. normal axis. lvh with strain pattern with downsloping st depressions v5-v6 with twi. unchanged from prior [**2105-3-12**]. telemetry demonstrated:pending 2d-echocardiogram performed on [**2105-3-12**] demonstrated: as above cardiac cath performed on [**2105-3-13**] demonstrated: as above assessment and plan assessment and plan, as reviewed and discussed in multidisciplinary rounds patient is a 59f with nonischemic dilated cardiomyopathy admitted with progressive sob and intermittent cp with borderline elevated biomarkers at osh transferred for asa desensitization . #. asa desensitization: will perform asa desensitization per protocol. if asthma, adverse reaction more likely to occur at higher doses. anaphylaxis more likely to occur immediately at lower doses - asa desensitization protocol adjusted so 2-3 hour gap between steps 9 and 10 (162 and 325 mg) - singulair prior to asa administration - epi sc at bedside - benadryl, solummedrol prior to asa . #. cad/chest pain: pt found to have 2vd on cardiac cath. echo without focal wma so unclear if 2vd is true etiology of symptoms. trop i and ck elevated at osh but only slightly above upper limit normal and may be consistent with strain and heart failure exacerbation. ekg changes could also be c/w strain. [**month (only) 51**] benefit from revascularization, however, with 2vd, specifically rca lesion 70-80%. - continue plavix - asa desensitization per protocol - check biomarkers here and trend - check lfts, amylase, lipase since pain more epigastric in nature . #. pump: pt with non ischemic dilated cm of unknown etiology ef 20-25% with severe global hk. symptoms over last several months most c/w worsening decompensated systolic heart failure. possible exacerbatng factors include dietary indiscretion and recent viral illness, increased demand. on exam today still appears volume overloaded. no focal wma abnormalities to suggest ischemic event as cause. per notes, is not candidate for heart transplant [**2-9**] pulm htn and has refused icd in past. per osh records had elevated dig level. - continue lasix iv prn. gave 40 iv on arrival to assess response and will repeat prn. goal negative 1-1.5 liters per day - cxr in am - bnp for baseline - holding dig; check dig level - continue aldactone - hold ace [**2-9**] increased risk anaphylaxis and angioedema - continue bb . #. rhythm: sinus tach currently - continue beta blocker although will monitor since can worsen bronchospasm; consider change to carvedilol . #. asthma: pt has h/o increased bronchospasm with asa in past. will continue outpt regimen with solumedrol prior to asa - iv solumedrol prior to asa - continue advair - singulair prior to asa - albuterol nebs prn . #. anxiety/depression: continue celexa, valium, buspar . #. hypothyrodism: continue synthroid . #. fen: cardiac heart healthy low sodium . #. access: piv . #. ppx: hep sc, ppi, bowel regimen . #. code: full . #. dispo: pending above . . icu care nutrition: glycemic control: lines: 20 gauge - [**2105-3-13**] 08:15 pm prophylaxis: dvt: sq uf heparin stress ulcer: vap: comments: communication: patient discussed on interdisciplinary rounds comments: code status: full code disposition: icu ------ protected section ------ cardiology fellow addendum: pt seen and examined and case discussed with housestaff. briefly, this is a 59yo female w/ nonischemic dilated cardiomyopathy of unclear etiology, ef 20-25% admitted to nebh several days ago with symptoms of worsening heart failure (increasing dyspnea, chest pain, and diaphoresis) in the setting of temporary decreased dose of lasix and digoxin being held. she had an elevated bnp and cardiac biomarkers (tpn i 5.97) and underwent cardiac cath that showed known 50% proximal and 50% mid lad stenosis, and (per pt) new 70-80% distal rca stenosis. she is transferred for further management / pci, requiring asa desensitization first. pmh, social history, medications are per resident note. she is currently hemodynamically stable, but with signs of volume overload jvp to jaw, diffuse basilar crackles on lung exam. we will start aspirin desensitization tonight, and continue diuresis. her presentation is consistent with heart failure exacerbation and less likely primary acs especially given global dysfunction on echocardiogram, though degree of tpn elevation is concerning; team will review cath films (regarding rca stenosis) to assess benefit of revascularization. balance of plan per ccu resident note. [**first name8 (namepattern2) 4237**] [**last name (namepattern1) 5663**], f1 #[**numeric identifier 5664**] ------ protected section addendum entered by:[**name (ni) 4237**] [**last name (namepattern1) 5663**], md on:[**2105-3-14**] 01:21 ------",1
261,title: respiratory care: pt in on 2 lpm n/c with saturations of 99-100%. albuterol nebs administered q6 hrs with no adverse reactions followed by the in-exsufflator with inspiratory pressures of 21cmh20 followed by expiratory pressures 22 cmh20. pt tolerated tx well. pt has strong cough and was able to expectorate a small amount of thick yellow/tanish secretions.,0
262,"title: respiratory care: pt in on 2 lpm n/c with saturations of 99-100%. albuterol nebs administered q6 hrs with no adverse reactions followed by the in-exsufflator with inspiratory pressures of 21cmh20 followed by expiratory pressures 22 cmh20. pt tolerated tx well. pt has strong cough and was able to expectorate a small amount of thick yellow/tanish secretions. ------ protected section ------ inexsufflator treatment consisted of 3 cycles x5 breaths each. ------ protected section addendum entered by:[**name (ni) **] [**last name (namepattern1) 6029**], rrt on:[**2115-3-23**] 06:42 ------",0
263,"chief complaint: 24 hour events: sheath - start [**2105-3-13**] 08:22 pm note sheath started in other hospital arterial sheath - stop [**2105-3-13**] 08:34 pm note sheath started in other hospital arterial tolerated asa desensitization given lasix 40 iv allergies: penicillins rash; aspirin wheezing; last dose of antibiotics: infusions: other icu medications: furosemide (lasix) - [**2105-3-14**] 12:08 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2105-3-14**] 05:54 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.2 c (98.9 tcurrent: 37.2 c (98.9 hr: 100 (97 - 107) bpm bp: 100/56(48) {87/35(48) - 112/72(103)} mmhg rr: 20 (18 - 33) insp/min spo2: 100% heart rhythm: st (sinus tachycardia) total in: 200 ml po: 200 ml tf: ivf: blood products: total out: 880 ml 955 ml urine: 880 ml 955 ml ng: stool: drains: balance: -880 ml -755 ml respiratory support o2 delivery device: nasal cannula spo2: 100% abg: ///29/ physical examination vs - t 98.2, hr 105, bp 109/47, rr 22, 100% on 3l nc gen: wdwn middle aged female in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 10 cm. cv: pmi laterally displaced. tachy. reg. [**3-13**] holosystoli blowing urmur radiating to apex. normal s1, s2. chest: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. pt occasioannly tachypneic with anxiety. crackles in bases anteriorly. abd: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. ext: no c/c/e. no femoral bruits. r femoral dsg cdi. ext slightly mottled skin: no stasis dermatitis, ulcers, scars, or xanthomas. . pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ labs / radiology 302 k/ul 12.7 g/dl 167 mg/dl 1.0 mg/dl 29 meq/l 4.9 meq/l 18 mg/dl 96 meq/l 134 meq/l 38.6 % 10.4 k/ul [image002.jpg] [**2105-3-13**] 07:28 pm [**2105-3-14**] 03:15 am wbc 12.2 10.4 hct 37.6 38.6 plt 335 302 cr 1.0 tropt 0.10 glucose 167 other labs: pt / ptt / inr:15.8/28.4/1.4, ck / ckmb / troponin-t:120/4/0.10, alt / ast:65/40, alk phos / t bili:59/0.4, amylase / lipase:26/27, albumin:4.0 g/dl, ldh:311 iu/l, ca++:8.9 mg/dl, mg++:2.7 mg/dl, po4:3.5 mg/dl assessment and plan assessment and plan, as reviewed and discussed in multidisciplinary rounds patient is a 59f with nonischemic dilated cardiomyopathy admitted with progressive sob and intermittent cp with borderline elevated biomarkers at osh transferred for asa desensitization . #. asa desensitization: will perform asa desensitization per protocol. if asthma, adverse reaction more likely to occur at higher doses. anaphylaxis more likely to occur immediately at lower doses - asa desensitization protocol adjusted so 2-3 hour gap between steps 9 and 10 (162 and 325 mg) - singulair prior to asa administration - epi sc at bedside - benadryl, solumedrol prior to asa . #. cad/chest pain: pt found to have 2vd on cardiac cath. echo without focal wma so unclear if 2vd is true etiology of symptoms. trop i and ck elevated at osh but only slightly above upper limit normal and may be consistent with strain and heart failure exacerbation. ekg changes could also be c/w strain. [**month (only) 51**] benefit from revascularization, however, with 2vd, specifically rca lesion 70-80%. - continue plavix - asa desensitization per protocol - check biomarkers here and trend - check lfts, amylase, lipase since pain more epigastric in nature . #. pump: pt with non ischemic dilated cm of unknown etiology ef 20-25% with severe global hk. symptoms over last several months most c/w worsening decompensated systolic heart failure. possible exacerbatng factors include dietary indiscretion and recent viral illness, increased demand. on exam today still appears volume overloaded. no focal wma abnormalities to suggest ischemic event as cause. per notes, is not candidate for heart transplant [**2-9**] pulm htn and has refused icd in past. per osh records had elevated dig level. - continue lasix iv prn. gave 40 iv on arrival to assess response and will repeat prn. goal negative 1-1.5 liters per day - cxr in am - bnp for baseline - holding dig; check dig level - continue aldactone - hold ace [**2-9**] increased risk anaphylaxis and angioedema - continue bb . #. rhythm: sinus tach currently - continue beta blocker although will monitor since can worsen bronchospasm; consider change to carvedilol . #. asthma: pt has h/o increased bronchospasm with asa in past. will continue outpt regimen with solumedrol prior to asa - iv solumedrol prior to asa - continue advair - singulair prior to asa - albuterol nebs prn . #. anxiety/depression: continue celexa, valium, buspar . #. hypothyrodism: continue synthroid . #. fen: cardiac heart healthy low sodium . #. access: piv . #. ppx: hep sc, ppi, bowel regimen . #. code: full . #. dispo: pending above . . icu care nutrition: glycemic control: lines: 20 gauge - [**2105-3-13**] 08:15 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",1
264,"chief complaint: 24 hour events: - extubated - advanced diet - picc placed, cvc d/c'd - ep decreased pacer hr to 70 bpm - precedex weaned off picc line - start [**2178-2-12**] 01:10 pm invasive ventilation - stop [**2178-2-12**] 01:20 pm multi lumen - stop [**2178-2-12**] 01:59 pm allergies: sulfonamides unknown; a.c.e inhibitors angioedema; angiotensin receptor antagonist angioedema; keflex (oral) (cephalexin monohydrate) nausea/vomiting last dose of antibiotics: ampicillin - [**2178-2-10**] 09:56 am ciprofloxacin - [**2178-2-10**] 10:00 pm metronidazole - [**2178-2-11**] 07:40 am vancomycin - [**2178-2-11**] 10:00 pm ceftriaxone - [**2178-2-12**] 10:00 pm infusions: other icu medications: heparin sodium (prophylaxis) - [**2178-2-13**] 12:15 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2178-2-13**] 07:01 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 35.9 c (96.7 tcurrent: 35.8 c (96.5 hr: 70 (70 - 93) bpm bp: 125/46(73) {91/38(55) - 132/62(85)} mmhg rr: 18 (12 - 21) insp/min spo2: 100% on 2l nc heart rhythm: v paced cvp: 5 (5 - 5)mmhg total in: 2,300 ml 752 ml po: 950 ml 600 ml tf: 60 ml ivf: 1,290 ml 152 ml blood products: total out: 540 ml 160 ml urine: 540 ml 160 ml ng: stool: drains: balance: 1,760 ml 592 ml respiratory support o2 delivery device: 2l nasal cannula abg at 3am: 7.38/31/70/20/-5 physical examination general appearance: intubated. sedated, not following commands. eyes / conjunctiva: perrl head, ears, nose, throat: poor dentition cardiovascular: (s1: normal), (s2: normal), (murmur: systolic) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: diminished), (left dp pulse: diminished) respiratory / chest: diminished at bases bilaterally, otherwise clear abdominal: soft, bowel sounds present, distended, tenderness not able to assess extremities: right: absent, left: absent, no(t) cyanosis, no(t) clubbing neurologic: responds to: not assessed, oriented (to): self and place, movement: not assessed, tone: not assessed labs / radiology 322 k/ul 10.6 g/dl 89 mg/dl 1.2 mg/dl 20 meq/l 3.7 meq/l 26 mg/dl 111 meq/l 139 meq/l 34.8 % 51.6 k/ul [image002.jpg] [**2178-2-10**] 03:24 pm [**2178-2-11**] 02:45 am [**2178-2-11**] 03:45 am [**2178-2-11**] 02:34 pm [**2178-2-11**] 06:38 pm [**2178-2-12**] 03:47 am [**2178-2-12**] 04:12 am [**2178-2-12**] 01:13 pm [**2178-2-13**] 02:49 am [**2178-2-13**] 02:53 am wbc 18.8 25.2 34.9 51.6 hct 31.9 31.3 33.2 34.8 plt 271 264 232 322 cr 1.2 1.2 1.1 1.2 tco2 21 22 22 23 21 19 glucose 105 100 105 89 other labs: pt / ptt / inr:16.0/32.0/1.4, ck / ckmb / troponin-t:47/8/0.26, alt / ast:47/92, alk phos / t bili:174/0.5, amylase / lipase:73/11, differential-neuts:84.0 %, band:1.0 %, lymph:3.0 %, mono:7.0 %, eos:0.0 %, fibrinogen:229 mg/dl, lactic acid:0.9 mmol/l, albumin:2.6 g/dl, ldh:495 iu/l, ca++:8.7 mg/dl, mg++:2.4 mg/dl, po4:2.6 mg/dl [**2178-2-10**] 3:23 pm stool consistency: formed source: stool. fecal culture (pending): campylobacter culture (final [**2178-2-12**]): no campylobacter found. fecal culture - r/o vibrio (final [**2178-2-12**]): no vibrio found. fecal culture - r/o yersinia (final [**2178-2-12**]): no yersinia found. fecal culture - r/o e.coli 0157:h7 (pending): clostridium difficile toxin a & b test (final [**2178-2-11**]): feces negative for c.difficile toxin a & b by eia. (reference range-negative). bcx [**2-8**], [**2-11**], [**2-12**] ngtd cxr [**2178-2-13**] (my read) right-sided effusion looks improved assessment and plan this is a 72m with mds and h/o recurrent c diff who presented with septic shock and respiratory failure. . # respiratory failure: resolved. successfully extubated yesterday . # septic shock/ fever: resolved. afebrile with stable bp off pressors. unclear source. top differentials include recurrent c. diff, ischemic bowel disease, pna (aspiration pna/pneumonitis). all microbiology studies have been negative to date. - ct torso showing colitis. c. diff neg x 2. given the high suspicion, will check again. continue po vanc for empiric therapy of c. diff. iv flagyl stopped [**2-12**]. will need po vanc for at least 2 weeks after finishing ceftriaxone. consider vanc taper as well since pt has h/o recurrent c. diff - continue ceftriaxone for empiric coverage for pneumonia in the absence of microbiology data plan for a 10 day course - pleural effusions unlikely to be empyema, as they have been chronic; also free-flowing. will defer thoracentesis for now. - elevated white count today likely related to steroid administration x 3 days (stopped yesterday) and myelofibrosis (started hydroxylurea yesterday) . # steroids: cortstim 14.6->19.1. abnormal in the setting of acute illness. gave 3 days of hydrocort burst for support while in shock and intubated. stopped yesterday # cardiac: trop leak in the setting of demand ischemia. cardiac cath 3 years ago at [**hospital1 609**] showed no flow limiting lesions per patient. echo done; no evidence of new areas of dysfunction. deferred anticoagulation with heparin as acs/plaque rupture unlikely. - continue 325mg asa, simva - ep decr d demand pacing to 70 as pt doing better. . # change in mental status: resolved now off of all sedatives. mentating clearly. pt has tendency to become delirious during acute illnesses. did much better on precedex than on fentanyl & versed. patient s prior episodes of agitation may be an adverse reaction to benzos. . # idiopathic myelofibrosis: pt s outpt hematologist visited pt informally; wbc now 51 today (likely more reflective of myelofibrosis than infection given overall improvement in pt s condition) - resumed hydroxyurea yesterday; hold interferon - will email pt s hematologist dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 3805**] with an update . # chronic renal failure: at baseline, 1.1. uop not great- wait for pt to autodiurese - avoid nephrotoxins - follow cr . # paf with pacemaker: stable, v-paced at this time. - appreciate ep help; demand pacing was increased to 90 on admission for shock, then decreased to 70 yesterday as pt doing better - restart bbker today . # chf (ef of 45%): repeat echo showing stable ef. - hold lasix in the setting of normotension. . # h/o htn; now stable with sbp 110-130s. - restart metoprolol 12.5 mg [**hospital1 7**] today (pt on toprol 25 mg qday at home) - continue asa and simvastatin . # pvd: decreased pulses in lower extremities - hold pentoxyfilline for now . # coagulopathy: inr near 2. patient received vitamin k. inr now stable in mid-1 . # elevated liver enzymes; stable transaminases, t.bili improved - monitor lfts . # hypothyroidism: tsh is elevated but free t4 wnl. likely sick euthyroid in the setting of acute illness. - continue home dose synthroid . # fen: ivf prn, replete electrolytes, nutrition consult placed. advance diet as tolerated . # prophylaxis: pneumoboots, hsq, h2 blocker. pt consult placed. . # access: 1 piv, rij pulled yesterday, a line d/c d this am. . # code: full, confirmed with patient and his wife. . # communication: family; hcp is wife [**doctor first name 96**]: [**telephone/fax (1) 6184**]) . # disposition: transfer to floor later today icu care nutrition: glycemic control: lines: arterial line - [**2178-2-9**] 03:19 am picc line - [**2178-2-12**] 01:10 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",1
265,"cardiology consult date of service: [**2167-1-10**] requesting physician: [**name initial (nameis) 122**] / [**name2 (ni) 775**] initial consultation: inpatient presenting complaint: (other: + troponin) history of present illness: asked by [**name2 (ni) 122**] team to consult regarding + troponin in medically complex woman admitted with possible hematemesis on a background of shortness of breath. 65f with [**doctor first name **] medical history including dm, esrd s/p transplant, atrial fibrillation, diastolic dysfunction, and a reported history of pvd. no known coronary disease or history of mi, though omr notes refer to outside stress test with ""questional antero-apical infarct and peri-infarct ischemia"". given prior lack of angina or equivalent, she has been maintained on medical therapy with catheterization. she was well until ~ 3-4 days ago, when she reports feeling gradually worsening dyspnea on exertion. she was seen by her regular cardiologist. developed nausea and vomiting, leading to outside hospital presentation with at least one episode of hematemesis with a small amount of blood but a stable hematocrit. was given ffp and vitamin k. sbps nadired at ~80s in er now improved. gi consulted, thought syndrome c/[**initials (namepattern4) **] [**last name (namepattern4) 241**]-[**doctor last name 37**] tear but not clearly an active gib, hence endoscopy deferred for now. given reports of back pain and concern for aortic / esophageal pathology, a ct-chest/abd was performed. notable findings included rll collapose thought [**12-29**] mucous plug, small associated pleural effusion, and marked coronary calcifications. currently in [**month/day (2) 122**], where she has been hemodynamically stable. ecgs and cardiac biomarkers as below. no reports of chest pain. past medical history: s/p cadaveric renal transplant in [**2160**], diabetes c/b neuropathy, retinopathy,nephropathy, diastolic congestive heart failure, atrial fibrillation on warfarin, htn, peripheral vascular disease, cholelithiasis, hypothyroidism, chronic anemia, gerd. she has h/o screening colonoscopy several years ago. cad risk factors cad risk factors present diabetes mellitus, dyslipidemia, hypertension cardiovascular procedural history there is no history of: pci cabg pacemaker / icd allergies: codeine nausea/vomiting phenergan (oral) (promethazine hcl) hallucinations; current medications: vancomycin levaquin insulin clonidine prograf zetia thyroid replacement mmf prednisone asa 325 ppi iv physical exam awake, alert, nad jvp lungs pmi heart is abd no labs 116 9.8 57 3.5 19 4.8 97 107 142 29.3 8.3 [image002.jpg] [**2167-1-9**] 08:36 pm [**2167-1-10**] 03:24 am wbc 13.1 8.3 hgb 9.4 9.8 hct (serum) 28.1 29.3 plt 124 116 inr 1.9 1.9 ptt 40.8 43.7 na+ 143 142 k + (serum) 4.7 4.8 cl 108 107 hco3 19 19 bun 97 97 creatinine 3.2 3.5 glucose 58 57 ck 408 392 ck-mb 10 9 troponin t 0.77 0.92 abg: / / / 19 / values as of [**2167-1-10**] 03:24 am tests ecg: (date: [**2167-1-10**]), sinus brady, asmi with q-waves v1-v3, normal axis and intervals, minor nonspecific st-tw changes. prior tracings similar except for at least one demonstrating atrial fibrillation. assessment and plan 63f with multiple cardiac risk factors and presumed (thought not definitively diagnosed) coronary artery disease, atrial fibrillation, lvh and significant diastolic dysfunction. she is now admitted with dyspnea, nausea/vomiting and a single episode of questionable hematemesis no longer deemed indicative of a true gib. [**month/day/year 122**] team currently working with diagnosis of primary pulmonary process (as reflected by rll collapse and associated effusion). we are asked to comment on her + cardiac biomarkers, specifically whether this represents demand ischemia rather than an acute coronary syndrome. given her risk factors and the diffuse coronary calcification seen on her ct scan, she very likely has significant cad. her ecgs are suggestive of old anterior mi but there are no acute changes to suggest acs. we agree that the current biomarker trend remains consistent with demand from her other underlying pathology, and as such she does not require acs-specific therapy with heparin, clopidogrel, iib/iiia inhibitors, beta-blockade, etc. when her pulmonary process has been better characterized, it may be worthwhile to pursue a more definitive assessment of her coronary tree. catheterization would be limited somewhat by her tenuous renal function, but a repeat stress test with imaging would be helpful when the acute pathology has improved. recommendations continue aspirin 325mg qd for now. when back on coumadin, would change this to 81mg qd. add statin if no history of prior adverse reaction. no role for heparin or other systemic anticoagulation now for acs; heparin/coumadin when deemed otherwise safe for her afib. will f/u results of tte.",0
266,"cardiology consult date of service: [**2167-1-10**] requesting physician: [**name initial (nameis) 122**] / [**name2 (ni) 775**] initial consultation: inpatient presenting complaint: (other: + troponin) history of present illness: asked by [**name2 (ni) 122**] team to consult regarding + troponin in medically complex woman admitted with possible hematemesis on a background of shortness of breath. 65f with [**doctor first name **] medical history including dm, esrd s/p transplant, atrial fibrillation, diastolic dysfunction, and a reported history of pvd. no known coronary disease or history of mi, though omr notes refer to outside stress test ([**7-4**]) with ""questionable antero-apical infarct and peri-infarct ischemia"". given prior lack of angina or equivalent, she has been maintained on medical therapy with catheterization. at baseline she performs her adls and can walk a fair distance on flat ground, but struggles up stairs, in part due to significant claudication. she was well until ~ 3-4 days ago, when she reports feeling gradually worsening dyspnea on exertion without other symptoms of chf or systemic illness. she was seen by her regular cardiologist, who by her report did not make any medication changes. notably, she reports checking her blood pressure at home and finding values sbp ~200 or greater for most of the week. she called the transplant team, who adjusted her bp meds slightly. on the night prior to admission, she developed nausea and vomiting, leading to outside hospital presentation with at least one episode of hematemesis with a small amount of blood but a stable hematocrit. was given ffp and vitamin k. sbps nadired at ~80s in er now improved. gi consulted, thought syndrome c/[**initials (namepattern4) **] [**last name (namepattern4) 241**]-[**doctor last name 37**] tear but not clearly an active gib, hence endoscopy deferred for now. given reports of back pain and concern for aortic / esophageal pathology, a ct-chest/abd was performed. notable findings included rll collapose thought [**12-29**] mucous plug, small associated pleural effusion, and marked coronary calcifications. currently in [**month/day (2) 122**], where she has been hemodynamically stable. ecgs and cardiac biomarkers as below. no reports of chest pain. coughed up one large mucous plug by report, and currently feels back to her baseline. past medical history: s/p cadaveric renal transplant in [**2160**], diabetes c/b neuropathy,retinopathy,nephropathy, diastolic congestive heart failure, atrial fibrillation on warfarin, peripheral vascular disease stable severe claudication, followed by osh cardiologist. cholelithiasis, hypothyroidism, chronic anemia, gerd cad risk factors cad risk factors present diabetes mellitus, dyslipidemia, hypertension cardiovascular procedural history there is no history of: pci cabg pacemaker / icd allergies: codeine nausea/vomiting phenergan (oral) (promethazine hcl) hallucinations; current medications: vancomycin levaquin insulin clonidine prograf zetia thyroid replacement mmf prednisone asa 325 ppi iv physical exam awake, alert, nad jvp not distended sitting upright lungs notable for bronchial breath sounds on r with dull sounds in the lower lung field. no crackles on the left. pmi nondisplaced heart is regular with distant heart sounds abd soft no edema. groin and dp pulses not palpable. labs 116 9.8 57 3.5 19 4.8 97 107 142 29.3 8.3 [image002.jpg] [**2167-1-9**] 08:36 pm [**2167-1-10**] 03:24 am wbc 13.1 8.3 hgb 9.4 9.8 hct (serum) 28.1 29.3 plt 124 116 inr 1.9 1.9 ptt 40.8 43.7 na+ 143 142 k + (serum) 4.7 4.8 cl 108 107 hco3 19 19 bun 97 97 creatinine 3.2 3.5 glucose 58 57 ck 408 392 ck-mb 10 9 troponin t 0.77 0.92 abg: / / / 19 / values as of [**2167-1-10**] 03:24 am tests ecg: (date: [**2167-1-10**]), sinus brady, asmi with q-waves v1-v3, normal axis and intervals, minor nonspecific st-tw changes. prior tracings similar except for at least one demonstrating atrial fibrillation. assessment and plan 63f with multiple cardiac risk factors and presumed (thought not definitively diagnosed) coronary artery disease, atrial fibrillation, lvh and significant diastolic dysfunction. she is now admitted with subacute dyspnea, nausea/vomiting and a single episode of questionable hematemesis no longer deemed indicative of a true gib. [**month/day/year 122**] team currently working with diagnosis of primary pulmonary process (as reflected by rll collapse and associated effusion). we are asked to comment on her + cardiac biomarkers, specifically whether this represents demand ischemia rather than an acute coronary syndrome. given her risk factors and the diffuse coronary calcification seen on her ct scan, she very likely has significant cad. her ecgs are suggestive of old anterior mi but there are no acute changes to suggest acs. we agree that the current biomarker trend remains consistent with demand from her other underlying pathology, in particular her report of up to a week of poorly controlled blood pressure. when her pulmonary process has been better characterized, it may be worthwhile to pursue a more definitive assessment of her coronary tree. catheterization would be limited somewhat by her tenuous renal function, but a repeat stress test with imaging would be helpful when the acute pathology has improved. recommendations continue aspirin 325mg qd for now. when back on coumadin, would change this to 81mg qd. add statin if no history of prior adverse reaction. no role for heparin or other systemic anticoagulation now for acs; heparin/coumadin when deemed otherwise safe for her afib. will f/u results of tte. i will notify dr. [**last name (stitle) 5772**] (one of her cardiologists) that the patient has been admitted. [**first name8 (namepattern2) 209**] [**last name (namepattern1) 3701**], md x90493",0
267,"cardiology consult date of service: [**2167-1-10**] requesting physician: [**name initial (nameis) 122**] / [**name2 (ni) 775**] initial consultation: inpatient presenting complaint: (other: + troponin) history of present illness: asked by [**name2 (ni) 122**] team to consult regarding + troponin in medically complex woman admitted with possible hematemesis on a background of shortness of breath. 65f with [**doctor first name **] medical history including dm, esrd s/p transplant, atrial fibrillation, diastolic dysfunction, and a reported history of pvd. no known coronary disease or history of mi, though omr notes refer to outside stress test ([**7-4**]) with ""questionable antero-apical infarct and peri-infarct ischemia"". given prior lack of angina or equivalent, she has been maintained on medical therapy without catheterization. at baseline she performs her adls and can walk a fair distance on flat ground, but struggles up stairs, in part due to significant claudication. she was well until ~ 3-4 days ago, when she reports feeling gradually worsening dyspnea on exertion without other symptoms of chf or systemic illness. she was seen by her regular cardiologist, who by her report did not make any medication changes. notably, she reports checking her blood pressure at home and finding values sbp ~200 or greater for most of the week. she called the transplant team, who adjusted her bp meds slightly. on the night prior to admission, she developed nausea and vomiting, leading to outside hospital presentation with at least one episode of hematemesis with a small amount of blood but a stable hematocrit. was given ffp and vitamin k. sbps nadired at ~80s in er now improved. gi consulted, thought syndrome c/[**initials (namepattern4) **] [**last name (namepattern4) 241**]-[**doctor last name 37**] tear but not clearly an active gib, hence endoscopy deferred for now. given reports of back pain and concern for aortic / esophageal pathology, a ct-chest/abd was performed. notable findings included rll collapse thought [**12-29**] mucous plug, small associated pleural effusion, and marked coronary calcifications. currently in [**month/day (2) 122**], where she has been hemodynamically stable. ecgs and cardiac biomarkers as below. no reports of chest pain. coughed up one large mucous plug by report, and currently feels back to her baseline. past medical history: s/p cadaveric renal transplant in [**2160**], diabetes c/b neuropathy,retinopathy,nephropathy, diastolic congestive heart failure, atrial fibrillation on warfarin, peripheral vascular disease stable severe claudication, followed by osh cardiologist. cholelithiasis, hypothyroidism, chronic anemia, gerd cad risk factors cad risk factors present diabetes mellitus, dyslipidemia, hypertension cardiovascular procedural history there is no history of: pci cabg pacemaker / icd allergies: codeine nausea/vomiting phenergan (oral) (promethazine hcl) hallucinations; current medications: vancomycin levaquin insulin clonidine prograf zetia thyroid replacement mmf prednisone asa 325 ppi iv physical exam awake, alert, nad jvp not distended sitting upright lungs notable for bronchial breath sounds on r with dull sounds in the lower lung field. no crackles on the left. pmi nondisplaced heart is regular with distant heart sounds abd soft no edema. groin and dp pulses not palpable. labs 116 9.8 57 3.5 19 4.8 97 107 142 29.3 8.3 [image002.jpg] [**2167-1-9**] 08:36 pm [**2167-1-10**] 03:24 am wbc 13.1 8.3 hgb 9.4 9.8 hct (serum) 28.1 29.3 plt 124 116 inr 1.9 1.9 ptt 40.8 43.7 na+ 143 142 k + (serum) 4.7 4.8 cl 108 107 hco3 19 19 bun 97 97 creatinine 3.2 3.5 glucose 58 57 ck 408 392 ck-mb 10 9 troponin t 0.77 0.92 abg: / / / 19 / values as of [**2167-1-10**] 03:24 am tests ecg: (date: [**2167-1-10**]), sinus brady, asmi with q-waves v1-v3, normal axis and intervals, minor nonspecific st-tw changes. prior tracings similar except for at least one demonstrating atrial fibrillation. assessment and plan 63f with multiple cardiac risk factors and presumed (thought not definitively diagnosed) coronary artery disease, atrial fibrillation, lvh and significant diastolic dysfunction. she is now admitted with subacute dyspnea, nausea/vomiting and a single episode of questionable hematemesis no longer deemed indicative of a true gib. [**month/day/year 122**] team currently working with diagnosis of primary pulmonary process (as reflected by rll collapse and associated effusion). we are asked to comment on her + cardiac biomarkers, specifically whether this represents demand ischemia rather than an acute coronary syndrome. given her risk factors and the diffuse coronary calcification seen on her ct scan, she very likely has significant cad. her ecgs are suggestive of old anterior mi but there are no acute changes to suggest acs. we agree that the current biomarker trend remains consistent with demand from her other underlying pathology, in particular her report of up to a week of poorly controlled blood pressure. not currently in heart failure, though her diastolic dysfunction likely tolerates volume overload very poorly. when her pulmonary process has been better characterized, it may be worthwhile to pursue a more definitive assessment of her coronary tree. catheterization would be limited somewhat by her tenuous renal function, but a repeat stress test with imaging would be helpful when the acute pathology has improved. recommendations continue aspirin 325mg qd for now. when back on coumadin, would change this to 81mg qd. add statin if no history of prior adverse reaction. no role for heparin or other systemic anticoagulation now for acs; heparin/coumadin when deemed otherwise safe for her afib. will f/u results of tte. i will notify dr. [**last name (stitle) 5772**] (one of her cardiologists) that the patient has been admitted. he may help specify the timing of her next stress test. [**first name8 (namepattern2) 209**] [**last name (namepattern1) 3701**], md x90493",0
268,title: respiratory care: atrovent nebs administered @ 4:00 . bs are clear bilaterally in apecies with diminished bases. no adverse reactions following tx.,0
269,"title: chief complaint: change in mental status 24 hour events: stool culture - at [**2178-2-11**] 04:16 pm c.diff sample blood cultured - at [**2178-2-11**] 04:30 pm cvl - vent set rate down to 16 -> abg 7.37/36/171 --> decreased rate further to 14 --> 7.35/39/148 - fentanyl/versed d/c'd and precedex started with bolus - tube feeding started-> residual 140cc, so held - id rejected iv vancomycin. last dose 8 pm [**2178-2-11**] - heme recs: cont. hydroxyurea, hold ifn, replace vit k allergies: sulfonamides unknown; a.c.e inhibitors angioedema; angiotensin receptor antagonist angioedema; keflex (oral) (cephalexin monohydrate) nausea/vomiting last dose of antibiotics: ceftriaxone - [**2178-2-9**] 10:30 pm acyclovir - [**2178-2-10**] 06:00 am ampicillin - [**2178-2-10**] 09:56 am ciprofloxacin - [**2178-2-10**] 10:00 pm metronidazole - [**2178-2-11**] 07:40 am vancomycin - [**2178-2-11**] 10:00 pm infusions: dexmedetomidine (precedex) - 0.4 mcg/kg/hour other icu medications: famotidine (pepcid) - [**2178-2-11**] 08:00 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2178-2-12**] 06:50 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.2 c (97.1 tcurrent: 35.7 c (96.2 hr: 90 (90 - 92) bpm bp: 102/49(68) {88/46(61) - 175/87(120)} mmhg rr: 15 (12 - 22) insp/min spo2: 100% heart rhythm: v paced cvp: 12 (6 - 16)mmhg total in: 1,333 ml 187 ml po: tf: 77 ml 60 ml ivf: 1,186 ml 126 ml blood products: total out: 960 ml 170 ml urine: 960 ml 170 ml ng: stool: drains: balance: 373 ml 17 ml los + 8l respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml vt (spontaneous): 616 (616 - 616) ml rr (set): 14 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi: 24 pip: 17 cmh2o plateau: 10 cmh2o compliance: 61.7 cmh2o/ml spo2: 100% abg: 7.37/39/148/23/-2 ve: 6.6 l/min pao2 / fio2: 370 physical examination general appearance: intubated. sedated, not following commands. eyes / conjunctiva: perrl head, ears, nose, throat: poor dentition cardiovascular: (s1: normal), (s2: normal), (murmur: systolic) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: diminished), (left dp pulse: diminished) respiratory / chest: diminished at bases bilaterally, otherwise clear abdominal: soft, bowel sounds present, distended, tenderness not able to assess extremities: right: absent, left: absent, no(t) cyanosis, no(t) clubbing neurologic: responds to: not assessed, oriented (to): self and place, movement: not assessed, tone: not assessed labs / radiology 232 k/ul 10.1 g/dl 105 mg/dl 1.1 mg/dl 23 meq/l 4.1 meq/l 24 mg/dl 114 meq/l 142 meq/l 33.2 % 34.9 k/ul [image002.jpg] [**2178-2-9**] 10:28 pm [**2178-2-10**] 01:56 am [**2178-2-10**] 06:32 am [**2178-2-10**] 03:24 pm [**2178-2-11**] 02:45 am [**2178-2-11**] 03:45 am [**2178-2-11**] 02:34 pm [**2178-2-11**] 06:38 pm [**2178-2-12**] 03:47 am [**2178-2-12**] 04:12 am wbc 27.0 18.8 25.2 34.9 hct 34.5 31.9 31.3 33.2 plt [**telephone/fax (3) 6270**]32 cr 1.3 1.2 1.2 1.1 tco2 23 23 21 22 22 23 glucose 117 105 100 105 other labs: pt / ptt / inr:16.4/33.7/1.5, ck:51, alt / ast:50/124, alk phos / t bili:156/0.6, lactic acid:0.9 mmol/l, albumin:2.6 g/dl, ldh:429 iu/l, mg++:2.5 mg/dl, po4:3.1 mg/dl; c. diff neg x 2 assessment and plan this is a 72m with septic shock and respiratory failure. . # respiratory failure: improving. on admission, pt was hypoxic to low 90s on non-rebreather thus was intubated. likely due to septic shock. pt does have h/o chronic pleural effusion r>l. rsbi 141 this am however during rounds, had little respiratory drive. had difficulty lifting sedation on fentanyl & versed due to periods of agitation. zyprexa had little effect; can t use haldol due to risk of qt prolongation (490ms at baseline). did much better overnight on precedex. tolerating minimal pressure support this morning. - attempt extubation today - follow abg . # septic shock/ fever: unclear source. top differentials include recurrent c. diff, ischemic bowel disease, pna. all microbiology studies have been negative to date. - to improve bp, limit sedation and give ivf boluses judiciously (give if cvp and uop also down). goal map>60-65, sbp>90. - if pressor requirement increases, consider adding vasopressin - ct torso showing colitis. c. diff neg x 2. given the high suspicion, will check again. continue po vanc for empiric therapy of c. diff. will stop iv flagyl ([**2-12**]). radiographic results could be changes related to his prior episodes of c. diff. additional stool studies still pending. - continue ceftriaxone for empiric coverage for pneumonia in the absence of microbiology data - if above investigations negative for source of infection, consider diagnostic [**female first name (un) 217**] for ?empyema (low suspicion though, since fluid is free flowing and chronic) . # steroids: cortstim 14.6->19.1. abnormal in the setting of acute illness. started hydrocort 100 mg q8 hrs [**2-10**]. will stop on [**2-12**] given overall improvement. # cardiac: trop leak in the setting of demand ischemia. cardiac cath 3 years ago at [**hospital1 609**] showed no flow limiting lesions per patient. echo done; no evidence of new areas of dysfunction - continue 325mg asa, simva - hold heparin for now as suspicion of demand ischemia is high and pt is already coagulopathic (inr 1.6) - will ask ep to decrease rate of pacemaker as acute illness resolving. . # change in mental status: pt has tendency to become delirious during acute illnesses; or may be a presenting symptom of meningitis. did much better on precedex than on fentanyl & versed. patient s prior episodes of agitation may be an adverse reaction to benzos. . # idiopathic myelofibrosis: pt s outpt hematologist visited pt informally - resume hydroxyurea; hold interferon . # chronic renal failure: at baseline, 1.1 - avoid nephrotoxins - follow cr . # paf with pacemaker: stable, rate well-controlled. v-paced at this time. - ep saw patient, adjusted settings to increase ventricular demand pacing to 90. will re-consult and ask to decrease rate as patient has improved. . # chf (ef of 45%): repeat echo showing stable ef. - hold lasix in the setting of hypotension . # h/o htn - hold home dose of toprol xl 25mg daily in the setting of hypotension - continue asa and simvastatin . # pvd: decreased pulses in lower extremities - hold pentoxyfilline for now . # coagulopathy: inr near 2. patient received vitamin k. inr now 1.5 - unclear etiology - site of rij oozing continuously -> will place a picc instead and pull the line and send tip for cx . # elevated liver enzymes; stable transaminases, t.bili improved - monitor lfts . # hypothyroidism: tsh is elevated but free t4 wnl. likely sick euthyroid in the setting of acute illness. - continue home dose synthroid . # fen: ivf prn, replete electrolytes, nutrition consult placed. tf held overnight due to residuals. will consider po diet post-extubation if ms improved. . # prophylaxis: pneumoboots, start hsq today as inr is now 1.6, h2 blocker. . # access: 1 piv, rij (place [**2178-2-9**]), a line (placed [**2178-2-9**]) . # code: full, confirmed with patient and his wife. . # communication: family; hcp is wife [**doctor first name 96**]: [**telephone/fax (1) 6184**]) . # disposition: icu for now icu care nutrition: glycemic control: lines: arterial line - [**2178-2-9**] 03:19 am multi lumen - [**2178-2-9**] 04:15 am prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",1
270,"title: chief complaint: change in mental status 24 hour events: stool culture - at [**2178-2-11**] 04:16 pm c.diff sample blood cultured - at [**2178-2-11**] 04:30 pm cvl - vent set rate down to 16 -> abg 7.37/36/171 --> decreased rate further to 14 --> 7.35/39/148 - fentanyl/versed d/c'd and precedex started with bolus - tube feeding started-> residual 140cc, so held - id rejected iv vancomycin. last dose 8 pm [**2178-2-11**] - heme recs: cont. hydroxyurea, hold ifn, replace vit k allergies: sulfonamides unknown; a.c.e inhibitors angioedema; angiotensin receptor antagonist angioedema; keflex (oral) (cephalexin monohydrate) nausea/vomiting last dose of antibiotics: ceftriaxone - [**2178-2-9**] 10:30 pm acyclovir - [**2178-2-10**] 06:00 am ampicillin - [**2178-2-10**] 09:56 am ciprofloxacin - [**2178-2-10**] 10:00 pm metronidazole - [**2178-2-11**] 07:40 am vancomycin - [**2178-2-11**] 10:00 pm infusions: dexmedetomidine (precedex) - 0.4 mcg/kg/hour other icu medications: famotidine (pepcid) - [**2178-2-11**] 08:00 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2178-2-12**] 06:50 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.2 c (97.1 tcurrent: 35.7 c (96.2 hr: 90 (90 - 92) bpm bp: 102/49(68) {88/46(61) - 175/87(120)} mmhg rr: 15 (12 - 22) insp/min spo2: 100% heart rhythm: v paced cvp: 12 (6 - 16)mmhg total in: 1,333 ml 187 ml po: tf: 77 ml 60 ml ivf: 1,186 ml 126 ml blood products: total out: 960 ml 170 ml urine: 960 ml 170 ml ng: stool: drains: balance: 373 ml 17 ml los + 8l respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml vt (spontaneous): 616 (616 - 616) ml rr (set): 14 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi: 24 pip: 17 cmh2o plateau: 10 cmh2o compliance: 61.7 cmh2o/ml spo2: 100% abg: 7.37/39/148/23/-2 ve: 6.6 l/min pao2 / fio2: 370 physical examination general appearance: intubated. sedated, not following commands. eyes / conjunctiva: perrl head, ears, nose, throat: poor dentition cardiovascular: (s1: normal), (s2: normal), (murmur: systolic) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: diminished), (left dp pulse: diminished) respiratory / chest: diminished at bases bilaterally, otherwise clear abdominal: soft, bowel sounds present, distended, tenderness not able to assess extremities: right: absent, left: absent, no(t) cyanosis, no(t) clubbing neurologic: responds to: not assessed, oriented (to): self and place, movement: not assessed, tone: not assessed labs / radiology 232 k/ul 10.1 g/dl 105 mg/dl 1.1 mg/dl 23 meq/l 4.1 meq/l 24 mg/dl 114 meq/l 142 meq/l 33.2 % 34.9 k/ul [image002.jpg] [**2178-2-9**] 10:28 pm [**2178-2-10**] 01:56 am [**2178-2-10**] 06:32 am [**2178-2-10**] 03:24 pm [**2178-2-11**] 02:45 am [**2178-2-11**] 03:45 am [**2178-2-11**] 02:34 pm [**2178-2-11**] 06:38 pm [**2178-2-12**] 03:47 am [**2178-2-12**] 04:12 am wbc 27.0 18.8 25.2 34.9 hct 34.5 31.9 31.3 33.2 plt [**telephone/fax (3) 6270**]32 cr 1.3 1.2 1.2 1.1 tco2 23 23 21 22 22 23 glucose 117 105 100 105 other labs: pt / ptt / inr:16.4/33.7/1.5, ck:51, alt / ast:50/124, alk phos / t bili:156/0.6, lactic acid:0.9 mmol/l, albumin:2.6 g/dl, ldh:429 iu/l, mg++:2.5 mg/dl, po4:3.1 mg/dl; c. diff neg x 2 assessment and plan this is a 72m with septic shock and respiratory failure. . # respiratory failure: improving. on admission, pt was hypoxic to low 90s on non-rebreather thus was intubated. likely due to septic shock. pt does have h/o chronic pleural effusion r>l. rsbi 141 this am however during rounds, had little respiratory drive. had difficulty lifting sedation on fentanyl & versed due to periods of agitation. zyprexa had little effect; can t use haldol due to risk of qt prolongation (490ms at baseline). did much better overnight on precedex. tolerating minimal pressure support this morning. - attempt extubation today - follow abg . # septic shock/ fever: unclear source. top differentials include recurrent c. diff, ischemic bowel disease, pna. all microbiology studies have been negative to date. - to improve bp, limit sedation and give ivf boluses judiciously (give if cvp and uop also down). goal map>60-65, sbp>90. - if pressor requirement increases, consider adding vasopressin - ct torso showing colitis. c. diff neg x 2. given the high suspicion, will check again. continue po vanc for empiric therapy of c. diff. will stop iv flagyl ([**2-12**]). radiographic results could be changes related to his prior episodes of c. diff. additional stool studies still pending. - continue ceftriaxone for empiric coverage for pneumonia in the absence of microbiology data - if above investigations negative for source of infection, consider diagnostic [**female first name (un) 217**] for ?empyema (low suspicion though, since fluid is free flowing and chronic) . # steroids: cortstim 14.6->19.1. abnormal in the setting of acute illness. started hydrocort 100 mg q8 hrs [**2-10**]. will stop on [**2-12**] given overall improvement. # cardiac: trop leak in the setting of demand ischemia. cardiac cath 3 years ago at [**hospital1 609**] showed no flow limiting lesions per patient. echo done; no evidence of new areas of dysfunction - continue 325mg asa, simva - hold heparin for now as suspicion of demand ischemia is high and pt is already coagulopathic (inr 1.6) - will ask ep to decrease rate of pacemaker as acute illness resolving. . # change in mental status: pt has tendency to become delirious during acute illnesses; or may be a presenting symptom of meningitis. did much better on precedex than on fentanyl & versed. patient s prior episodes of agitation may be an adverse reaction to benzos. . # idiopathic myelofibrosis: pt s outpt hematologist visited pt informally - resume hydroxyurea; hold interferon . # chronic renal failure: at baseline, 1.1 - avoid nephrotoxins - follow cr . # paf with pacemaker: stable, rate well-controlled. v-paced at this time. - ep saw patient, adjusted settings to increase ventricular demand pacing to 90. will re-consult and ask to decrease rate as patient has improved. . # chf (ef of 45%): repeat echo showing stable ef. - hold lasix in the setting of hypotension . # h/o htn - hold home dose of toprol xl 25mg daily in the setting of hypotension - continue asa and simvastatin . # pvd: decreased pulses in lower extremities - hold pentoxyfilline for now . # coagulopathy: inr near 2. patient received vitamin k. inr now 1.5 - unclear etiology - site of rij oozing continuously -> will place a picc instead and pull the line and send tip for cx . # elevated liver enzymes; stable transaminases, t.bili improved - monitor lfts . # hypothyroidism: tsh is elevated but free t4 wnl. likely sick euthyroid in the setting of acute illness. - continue home dose synthroid . # fen: ivf prn, replete electrolytes, nutrition consult placed. tf held overnight due to residuals. will consider po diet post-extubation if ms improved. . # prophylaxis: pneumoboots, start hsq today as inr is now 1.6, h2 blocker. . # access: 1 piv, rij (place [**2178-2-9**]), a line (placed [**2178-2-9**]) . # code: full, confirmed with patient and his wife. . # communication: family; hcp is wife [**doctor first name 96**]: [**telephone/fax (1) 6184**]) . # disposition: icu for now icu care nutrition: glycemic control: lines: arterial line - [**2178-2-9**] 03:19 am multi lumen - [**2178-2-9**] 04:15 am prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition: ------ protected section ------ correction to access: patient had picc line placed today. a-line already removed. will remove ij once clear that patient is stable and will not require reintubation and pressors. ------ protected section addendum entered by:[**name (ni) 914**] [**last name (namepattern1) 3143**], md on:[**2178-2-12**] 14:31 ------",1
271,"chief complaint: 24 hour events: - extubated - advanced diet - picc placed, cvc d/c'd - ep decreased pacer hr to 70 bpm - precedex weaned off picc line - start [**2178-2-12**] 01:10 pm invasive ventilation - stop [**2178-2-12**] 01:20 pm multi lumen - stop [**2178-2-12**] 01:59 pm allergies: sulfonamides unknown; a.c.e inhibitors angioedema; angiotensin receptor antagonist angioedema; keflex (oral) (cephalexin monohydrate) nausea/vomiting last dose of antibiotics: ampicillin - [**2178-2-10**] 09:56 am ciprofloxacin - [**2178-2-10**] 10:00 pm metronidazole - [**2178-2-11**] 07:40 am vancomycin - [**2178-2-11**] 10:00 pm ceftriaxone - [**2178-2-12**] 10:00 pm infusions: other icu medications: heparin sodium (prophylaxis) - [**2178-2-13**] 12:15 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2178-2-13**] 07:01 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 35.9 c (96.7 tcurrent: 35.8 c (96.5 hr: 70 (70 - 93) bpm bp: 125/46(73) {91/38(55) - 132/62(85)} mmhg rr: 18 (12 - 21) insp/min spo2: 100% heart rhythm: v paced cvp: 5 (5 - 5)mmhg total in: 2,300 ml 752 ml po: 950 ml 600 ml tf: 60 ml ivf: 1,290 ml 152 ml blood products: total out: 540 ml 160 ml urine: 540 ml 160 ml ng: stool: drains: balance: 1,760 ml 592 ml respiratory support o2 delivery device: nasal cannula ventilator mode: cpap/psv vt (set): 500 (500 - 500) ml vt (spontaneous): 586 (586 - 586) ml ps : 5 cmh2o rr (set): 14 rr (spontaneous): 13 peep: 0 cmh2o fio2: 40% pip: 13 cmh2o spo2: 100% abg: 7.38/31/70/20/-5 ve: 7.7 l/min pao2 / fio2: 175 physical examination general appearance: intubated. sedated, not following commands. eyes / conjunctiva: perrl head, ears, nose, throat: poor dentition cardiovascular: (s1: normal), (s2: normal), (murmur: systolic) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: diminished), (left dp pulse: diminished) respiratory / chest: diminished at bases bilaterally, otherwise clear abdominal: soft, bowel sounds present, distended, tenderness not able to assess extremities: right: absent, left: absent, no(t) cyanosis, no(t) clubbing neurologic: responds to: not assessed, oriented (to): self and place, movement: not assessed, tone: not assessed labs / radiology 322 k/ul 10.6 g/dl 89 mg/dl 1.2 mg/dl 20 meq/l 3.7 meq/l 26 mg/dl 111 meq/l 139 meq/l 34.8 % 51.6 k/ul [image002.jpg] [**2178-2-10**] 03:24 pm [**2178-2-11**] 02:45 am [**2178-2-11**] 03:45 am [**2178-2-11**] 02:34 pm [**2178-2-11**] 06:38 pm [**2178-2-12**] 03:47 am [**2178-2-12**] 04:12 am [**2178-2-12**] 01:13 pm [**2178-2-13**] 02:49 am [**2178-2-13**] 02:53 am wbc 18.8 25.2 34.9 51.6 hct 31.9 31.3 33.2 34.8 plt 271 264 232 322 cr 1.2 1.2 1.1 1.2 tco2 21 22 22 23 21 19 glucose 105 100 105 89 other labs: pt / ptt / inr:16.0/32.0/1.4, ck / ckmb / troponin-t:47/8/0.26, alt / ast:47/92, alk phos / t bili:174/0.5, amylase / lipase:73/11, differential-neuts:84.0 %, band:1.0 %, lymph:3.0 %, mono:7.0 %, eos:0.0 %, fibrinogen:229 mg/dl, lactic acid:0.9 mmol/l, albumin:2.6 g/dl, ldh:495 iu/l, ca++:8.7 mg/dl, mg++:2.4 mg/dl, po4:2.6 mg/dl assessment and plan this is a 72m with septic shock and respiratory failure. . # respiratory failure: improving. on admission, pt was hypoxic to low 90s on non-rebreather thus was intubated. likely due to septic shock. pt does have h/o chronic pleural effusion r>l. rsbi 141 this am however during rounds, had little respiratory drive. had difficulty lifting sedation on fentanyl & versed due to periods of agitation. zyprexa had little effect; can t use haldol due to risk of qt prolongation (490ms at baseline). did much better overnight on precedex. tolerating minimal pressure support this morning. - attempt extubation today - follow abg . # septic shock/ fever: unclear source. top differentials include recurrent c. diff, ischemic bowel disease, pna. all microbiology studies have been negative to date. - to improve bp, limit sedation and give ivf boluses judiciously (give if cvp and uop also down). goal map>60-65, sbp>90. - if pressor requirement increases, consider adding vasopressin - ct torso showing colitis. c. diff neg x 2. given the high suspicion, will check again. continue po vanc for empiric therapy of c. diff. will stop iv flagyl ([**2-12**]). radiographic results could be changes related to his prior episodes of c. diff. additional stool studies still pending. - continue ceftriaxone for empiric coverage for pneumonia in the absence of microbiology data - if above investigations negative for source of infection, consider diagnostic [**female first name (un) 217**] for ?empyema (low suspicion though, since fluid is free flowing and chronic) . # steroids: cortstim 14.6->19.1. abnormal in the setting of acute illness. started hydrocort 100 mg q8 hrs [**2-10**]. will stop on [**2-12**] given overall improvement. # cardiac: trop leak in the setting of demand ischemia. cardiac cath 3 years ago at [**hospital1 609**] showed no flow limiting lesions per patient. echo done; no evidence of new areas of dysfunction - continue 325mg asa, simva - hold heparin for now as suspicion of demand ischemia is high and pt is already coagulopathic (inr 1.6) - will ask ep to decrease rate of pacemaker as acute illness resolving. . # change in mental status: pt has tendency to become delirious during acute illnesses; or may be a presenting symptom of meningitis. did much better on precedex than on fentanyl & versed. patient s prior episodes of agitation may be an adverse reaction to benzos. . # idiopathic myelofibrosis: pt s outpt hematologist visited pt informally - resume hydroxyurea; hold interferon . # chronic renal failure: at baseline, 1.1 - avoid nephrotoxins - follow cr . # paf with pacemaker: stable, rate well-controlled. v-paced at this time. - ep saw patient, adjusted settings to increase ventricular demand pacing to 90. will re-consult and ask to decrease rate as patient has improved. . # chf (ef of 45%): repeat echo showing stable ef. - hold lasix in the setting of hypotension . # h/o htn - hold home dose of toprol xl 25mg daily in the setting of hypotension - continue asa and simvastatin . # pvd: decreased pulses in lower extremities - hold pentoxyfilline for now . # coagulopathy: inr near 2. patient received vitamin k. inr now 1.5 - unclear etiology - site of rij oozing continuously -> will place a picc instead and pull the line and send tip for cx . # elevated liver enzymes; stable transaminases, t.bili improved - monitor lfts . # hypothyroidism: tsh is elevated but free t4 wnl. likely sick euthyroid in the setting of acute illness. - continue home dose synthroid . # fen: ivf prn, replete electrolytes, nutrition consult placed. tf held overnight due to residuals. will consider po diet post-extubation if ms improved. . # prophylaxis: pneumoboots, start hsq today as inr is now 1.6, h2 blocker. . # access: 1 piv, rij (place [**2178-2-9**]), a line (placed [**2178-2-9**]) . # code: full, confirmed with patient and his wife. . # communication: family; hcp is wife [**doctor first name 96**]: [**telephone/fax (1) 6184**]) . # disposition: icu for now icu care nutrition: glycemic control: lines: arterial line - [**2178-2-9**] 03:19 am picc line - [**2178-2-12**] 01:10 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",1
272,"chief complaint: 24 hour events: - extubated - advanced diet - picc placed, cvc d/c'd - ep decreased pacer hr to 70 bpm - precedex weaned off picc line - start [**2178-2-12**] 01:10 pm invasive ventilation - stop [**2178-2-12**] 01:20 pm multi lumen - stop [**2178-2-12**] 01:59 pm allergies: sulfonamides unknown; a.c.e inhibitors angioedema; angiotensin receptor antagonist angioedema; keflex (oral) (cephalexin monohydrate) nausea/vomiting last dose of antibiotics: ampicillin - [**2178-2-10**] 09:56 am ciprofloxacin - [**2178-2-10**] 10:00 pm metronidazole - [**2178-2-11**] 07:40 am vancomycin - [**2178-2-11**] 10:00 pm ceftriaxone - [**2178-2-12**] 10:00 pm infusions: other icu medications: heparin sodium (prophylaxis) - [**2178-2-13**] 12:15 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2178-2-13**] 07:01 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 35.9 c (96.7 tcurrent: 35.8 c (96.5 hr: 70 (70 - 93) bpm bp: 125/46(73) {91/38(55) - 132/62(85)} mmhg rr: 18 (12 - 21) insp/min spo2: 100% on 2l nc heart rhythm: v paced cvp: 5 (5 - 5)mmhg total in: 2,300 ml 752 ml po: 950 ml 600 ml tf: 60 ml ivf: 1,290 ml 152 ml blood products: total out: 540 ml 160 ml urine: 540 ml 160 ml ng: stool: drains: balance: 1,760 ml 592 ml respiratory support o2 delivery device: 2l nasal cannula abg at 3am: 7.38/31/70/20/-5 physical examination general appearance: intubated. sedated, not following commands. eyes / conjunctiva: perrl head, ears, nose, throat: poor dentition cardiovascular: (s1: normal), (s2: normal), (murmur: systolic) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: diminished), (left dp pulse: diminished) respiratory / chest: diminished at bases bilaterally, otherwise clear abdominal: soft, bowel sounds present, distended, tenderness not able to assess extremities: right: absent, left: absent, no(t) cyanosis, no(t) clubbing neurologic: responds to: not assessed, oriented (to): self and place, movement: not assessed, tone: not assessed labs / radiology 322 k/ul 10.6 g/dl 89 mg/dl 1.2 mg/dl 20 meq/l 3.7 meq/l 26 mg/dl 111 meq/l 139 meq/l 34.8 % 51.6 k/ul [image002.jpg] [**2178-2-10**] 03:24 pm [**2178-2-11**] 02:45 am [**2178-2-11**] 03:45 am [**2178-2-11**] 02:34 pm [**2178-2-11**] 06:38 pm [**2178-2-12**] 03:47 am [**2178-2-12**] 04:12 am [**2178-2-12**] 01:13 pm [**2178-2-13**] 02:49 am [**2178-2-13**] 02:53 am wbc 18.8 25.2 34.9 51.6 hct 31.9 31.3 33.2 34.8 plt 271 264 232 322 cr 1.2 1.2 1.1 1.2 tco2 21 22 22 23 21 19 glucose 105 100 105 89 other labs: pt / ptt / inr:16.0/32.0/1.4, ck / ckmb / troponin-t:47/8/0.26, alt / ast:47/92, alk phos / t bili:174/0.5, amylase / lipase:73/11, differential-neuts:84.0 %, band:1.0 %, lymph:3.0 %, mono:7.0 %, eos:0.0 %, fibrinogen:229 mg/dl, lactic acid:0.9 mmol/l, albumin:2.6 g/dl, ldh:495 iu/l, ca++:8.7 mg/dl, mg++:2.4 mg/dl, po4:2.6 mg/dl [**2178-2-10**] 3:23 pm stool consistency: formed source: stool. fecal culture (pending): campylobacter culture (final [**2178-2-12**]): no campylobacter found. fecal culture - r/o vibrio (final [**2178-2-12**]): no vibrio found. fecal culture - r/o yersinia (final [**2178-2-12**]): no yersinia found. fecal culture - r/o e.coli 0157:h7 (pending): clostridium difficile toxin a & b test (final [**2178-2-11**]): feces negative for c.difficile toxin a & b by eia. (reference range-negative). bcx [**2-8**], [**2-11**], [**2-12**] ngtd cxr [**2178-2-13**] (my read) right-sided effusion looks improved assessment and plan this is a 72m with mds and h/o recurrent c diff who presented with septic shock and respiratory failure. . # respiratory failure: resolved. successfully extubated yesterday . # septic shock/ fever: resolved. afebrile with stable bp off pressors. unclear source. top differentials include recurrent c. diff, ischemic bowel disease, pna (aspiration pna/pneumonitis). all microbiology studies have been negative to date. - ct torso showing colitis. c. diff neg x 2. given the high suspicion, will check again. continue po vanc for empiric therapy of c. diff. iv flagyl stopped [**2-12**]. will need po vanc for at least 2 weeks after finishing ceftriaxone. consider vanc taper as well since pt has h/o recurrent c. diff - continue ceftriaxone for empiric coverage for pneumonia in the absence of microbiology data plan for a 10 day course - pleural effusions unlikely to be empyema, as they have been chronic; also free-flowing. will defer thoracentesis for now. - elevated white count today likely related to steroid administration x 3 days (stopped yesterday) and myelofibrosis (started hydroxylurea yesterday) . # steroids: cortstim 14.6->19.1. abnormal in the setting of acute illness. gave 3 days of hydrocort burst for support while in shock and intubated. stopped yesterday # cardiac: trop leak in the setting of demand ischemia. cardiac cath 3 years ago at [**hospital1 609**] showed no flow limiting lesions per patient. echo done; no evidence of new areas of dysfunction. deferred anticoagulation with heparin as acs/plaque rupture unlikely. - continue 325mg asa, simva - ep decr d demand pacing to 70 as pt doing better. . # change in mental status: resolved now off of all sedatives. mentating clearly. pt has tendency to become delirious during acute illnesses. did much better on precedex than on fentanyl & versed. patient s prior episodes of agitation may be an adverse reaction to benzos. . # idiopathic myelofibrosis: pt s outpt hematologist visited pt informally; wbc now 51 today (likely more reflective of myelofibrosis than infection given overall improvement in pt s condition) - resumed hydroxyurea yesterday; hold interferon - will email pt s hematologist dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 3805**] with an update . # chronic renal failure: at baseline, 1.1. uop not great- wait for pt to autodiurese - avoid nephrotoxins - follow cr . # paf with pacemaker: stable, v-paced at this time. - appreciate ep help; demand pacing was increased to 90 on admission for shock, then decreased to 70 yesterday as pt doing better - restart bbker today . # chf (ef of 45%): repeat echo showing stable ef. - hold lasix in the setting of normotension. . # h/o htn; now stable with sbp 110-130s. - restart metoprolol 12.5 mg [**hospital1 7**] today (pt on toprol 25 mg qday at home) - continue asa and simvastatin . # pvd: decreased pulses in lower extremities - hold pentoxyfilline for now . # coagulopathy: inr near 2. patient received vitamin k. inr now stable in mid-1 . # elevated liver enzymes; stable transaminases, t.bili improved - monitor lfts . # hypothyroidism: tsh is elevated but free t4 wnl. likely sick euthyroid in the setting of acute illness. - continue home dose synthroid . # fen: ivf prn, replete electrolytes, nutrition consult placed. advance diet as tolerated . # prophylaxis: pneumoboots, hsq, h2 blocker. pt consult placed. . # access: 1 piv, rij pulled yesterday, a line d/c d this am. . # code: full, confirmed with patient and his wife. . # communication: family; hcp is wife [**doctor first name 96**]: [**telephone/fax (1) 6184**]) . # disposition: transfer to floor later today icu care nutrition: glycemic control: lines: arterial line - [**2178-2-9**] 03:19 am picc line - [**2178-2-12**] 01:10 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition: ------ protected section ------ micu attending addendum i saw and examined the patient, and was physically present with the icu team for the key portions of the services provided. i agree with the note above, including the assessment and plan. i would emphasize and add the following points: 72m idiopathic myelofibrosis on ifn, af s/p ppm, ckd, dcm (45%), hypothyroidism, c. diff p/w fevers and altered mental status. extubated, comfortable. picc placed. exam notable for tm 98.7 bp 138/60 hr 70/paced rr 22 with sat 98 on ra. alert, comfortable. coarse bs b. rrr s1s2. soft +bs. [**month (only) **] bs. tr edema. labs notable for wbc 51k, hct 34, k+ 3.7, cr 1.2. agree with plan to manage pneumonia with ctx x10days. will continue po vanco for resolving c. diff for an additional 2 weeks +/- taper. will hold off on tap of chronic transudative r effusion, unless he becomes symptomatic. oob, adat, cpt today. he ruled in for mi; will continue asa and continue to monitor while treating primary medical illness, and will restart metoprolol today and lasix in am. for af, pacer demand rate decreased to 70bpm. myelofibrosis present but stable, continue hydroxyurea and d/w onc re timing of further ifn rx. above d/w patient and wife at bedside. remainder of plan as outlined above. total time: 35 min ------ protected section addendum entered by:[**name (ni) 453**] [**last name (namepattern1) 775**], md on:[**2178-2-13**] 04:24 pm ------",1
273,"chief complaint: 24 hour events: wound culture - at [**2179-4-19**] 02:50 pm r knee tap -continued on lasix gtt with >100cc per hour uop, continued milrinone -still on neo at 10pm but maps high 50s, so have asked to wean. by am, have weaned down to 1.5 from 3 -code status confirmed with wife as dnr/dni per [**doctor first name 6208**]. -had knee tapped->not septic -ordered ambien for sleep (reportedly takes at home and had 2 nights ago with good effect, no adverse reaction) allergies: neomycin sulfate/hc (topical) unknown; unknown; beet unknown; last dose of antibiotics: infusions: milrinone - 0.5 mcg/kg/min phenylephrine - 1.5 mcg/kg/min furosemide (lasix) - 10 mg/hour other icu medications: other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2179-4-20**] 06:05 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.4 c (97.6 tcurrent: 36.1 c (97 hr: 72 (56 - 72) bpm bp: 104/79(85) {82/35(47) - 113/79(85)} mmhg rr: 26 (14 - 27) insp/min spo2: 96% heart rhythm: sr (sinus rhythm) wgt (current): 62.3 kg (admission): 66.3 kg cvp: 15 (10 - 20)mmhg total in: 2,925 ml 461 ml po: 770 ml tf: ivf: 2,155 ml 461 ml blood products: total out: 4,590 ml 2,040 ml urine: 4,590 ml 2,040 ml ng: stool: drains: balance: -1,665 ml -1,579 ml respiratory support o2 delivery device: nasal cannula spo2: 95% abg: ///24/ physical examination general appearance: no acute distress eyes / conjunctiva: conjunctiva pale head, ears, nose, throat: normocephalic cardiovascular: (s1: normal), (s2: normal) peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) respiratory / chest: (breath sounds: crackles : bibasilar) abdominal: soft, non-tender, bowel sounds present extremities: trace bilateral lower extremity edema, right knee with erythema, tenderness, and swelling musculoskeletal: muscle wasting skin: not assessed neurologic: attentive, follows simple commands, responds to: verbal stimuli, oriented (to): person, place, and time, movement: not assessed, tone: not assessed labs / radiology 137 k/ul 9.7 g/dl 120 mg/dl 4.1 mg/dl 24 meq/l 3.9 meq/l 100 mg/dl 103 meq/l 139 meq/l 28.3 % 7.8 k/ul [image002.jpg] [**2179-4-18**] 03:54 am [**2179-4-18**] 02:41 pm [**2179-4-19**] 04:27 am [**2179-4-19**] 04:26 pm [**2179-4-20**] 03:28 am wbc 5.2 8.1 7.8 hct 28.4 31.4 29.7 29.5 28.3 plt 90 124 137 cr 4.3 4.2 4.4 4.3 4.1 glucose 90 143 138 116 120 other labs: pt / ptt / inr:17.3/33.0/1.6, ca++:9.1 mg/dl, mg++:2.4 mg/dl, po4:4.9 mg/dl assessment and plan 79 yo with pmh of cad p/w hypotension x 6 weeks, guaiac positive stool, and arf. 1. acute on chronic systolic and diastolic biventricular heart failure leading to cardiogenic shock etiology of his acute worsening of his heart failure is unclear. differential includes persistent and worsening mitral regurgitation, although precipitant is unclear. [**name2 (ni) 6188**] were negative for clot. plan is the following: - continue milrinone for inotropic support with phenylephrine to maintain peripheral tone. - aim for map goal of 50 - continue lasix drip to maintain urine output with goal of 2l negative today - consider adding metolazole 5mg [**hospital1 **] to achieve goal urine output 2. right knee effusion patient has evidence of right knee effusion with exam findings consistent with inflammation. etiology is unclear. - [**name2 (ni) **]lt rheum for right knee tap - continue cephalexin for now and consider broadening coverage if patient has signs of infection on tap 3. acute kidney injury: feurea suggests pre-renal etiology which is likely poor forward from heart failure. - continue heart failure treatment as described above, if creatinine does not improve, consider renal consult 4. gib/ulcers: plan per micu note: hct stable from [**4-8**] [**location (un) 755**] stay. known gastric ulcers from [**location (un) 755**]. - t and s - 2 18g iv - ppi [**hospital1 7**] - hold asa - check [**hospital1 **] hct and will call gi if patient has any evidence of bleeding 5. ascites: suspect volume from chf. can trend lfts. 6. cad: last cath in [**2176**], no ck leak initially to suggest infarction and no symptoms of acs. can consider angiography to evaluate for graft failure or restenosis, but would defer for now given renal impairment. - hold aspirin in the setting of guiac positive stool - hold beta blocker in the setting of low heart rate . 7. anemia: at recent baseline. see above re: gi bleed 8. pyuria: wbc [**7-21**]. asymptomatic. - culture finalized negative. 9. thrombocytopenia: ? [**3-15**] hepatic failure from right heart failure. also ? of mds per outpatient cardiologist. - follow # fen: no ivf, replete electrolytes, regular diet # prophylaxis: pneumoboots, ppi # access: 2 18g pivs # code: dnr/dni confirmed with patient # communication: patient icu care nutrition: glycemic control: lines: 18 gauge - [**2179-4-17**] 03:03 pm multi lumen - [**2179-4-18**] 11:29 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",0
274,"chief complaint: 24 hour events: wound culture - at [**2179-4-19**] 02:50 pm r knee tap -continued on lasix gtt with >100cc per hour uop, continued milrinone -still on neo at 10pm but maps high 50s, so have asked to wean. by am, have weaned down to 1.5 from 3 -code status confirmed with wife as dnr/dni per [**doctor first name 6208**]. -had knee tapped->not septic -ordered ambien for sleep (reportedly takes at home and had 2 nights ago with good effect, no adverse reaction) allergies: neomycin sulfate/hc (topical) unknown; unknown; beet unknown; last dose of antibiotics: infusions: milrinone - 0.5 mcg/kg/min phenylephrine - 1.5 mcg/kg/min furosemide (lasix) - 10 mg/hour other icu medications: other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2179-4-20**] 06:05 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.4 c (97.6 tcurrent: 36.1 c (97 hr: 72 (56 - 72) bpm bp: 104/79(85) {82/35(47) - 113/79(85)} mmhg rr: 26 (14 - 27) insp/min spo2: 96% heart rhythm: sr (sinus rhythm) wgt (current): 62.3 kg (admission): 66.3 kg cvp: 15 (10 - 20)mmhg total in: 2,925 ml 461 ml po: 770 ml tf: ivf: 2,155 ml 461 ml blood products: total out: 4,590 ml 2,040 ml urine: 4,590 ml 2,040 ml ng: stool: drains: balance: -1,665 ml -1,579 ml respiratory support o2 delivery device: nasal cannula spo2: 95% abg: ///24/ physical examination peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) skin: not assessed neurologic: responds to: not assessed, movement: not assessed, tone: not assessed labs / radiology 137 k/ul 9.7 g/dl 120 mg/dl 4.1 mg/dl 24 meq/l 3.9 meq/l 100 mg/dl 103 meq/l 139 meq/l 28.3 % 7.8 k/ul [image002.jpg] [**2179-4-18**] 03:54 am [**2179-4-18**] 02:41 pm [**2179-4-19**] 04:27 am [**2179-4-19**] 04:26 pm [**2179-4-20**] 03:28 am wbc 5.2 8.1 7.8 hct 28.4 31.4 29.7 29.5 28.3 plt 90 124 137 cr 4.3 4.2 4.4 4.3 4.1 glucose 90 143 138 116 120 other labs: pt / ptt / inr:17.3/33.0/1.6, ca++:9.1 mg/dl, mg++:2.4 mg/dl, po4:4.9 mg/dl assessment and plan heart failure (chf), systolic and diastolic, acute on chronic baseline ef 20% with regional variation, renal failure, acute (acute renal failure, arf) likely pre-renal etiology coronary artery bypass graft (cabg) coronary artery disease (cad, ischemic heart disease) bradycardia cellulitis .h/o hypotension (not shock) icu care nutrition: glycemic control: lines: 18 gauge - [**2179-4-17**] 03:03 pm multi lumen - [**2179-4-18**] 11:29 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",0
275,"chief complaint: 24 hour events: wound culture - at [**2179-4-19**] 02:50 pm r knee tap -continued on lasix gtt with >100cc per hour uop, continued milrinone -still on neo at 10pm but maps high 50s, so have asked to wean. by am, have weaned down to 1.5 from 3 -code status confirmed with wife as dnr/dni per [**doctor first name 6208**]. -had knee tapped->not septic -ordered ambien for sleep (reportedly takes at home and had 2 nights ago with good effect, no adverse reaction) allergies: neomycin sulfate/hc (topical) unknown; unknown; beet unknown; last dose of antibiotics: infusions: milrinone - 0.5 mcg/kg/min phenylephrine - 1.5 mcg/kg/min furosemide (lasix) - 10 mg/hour other icu medications: other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2179-4-20**] 06:05 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.4 c (97.6 tcurrent: 36.1 c (97 hr: 72 (56 - 72) bpm bp: 104/79(85) {82/35(47) - 113/79(85)} mmhg rr: 26 (14 - 27) insp/min spo2: 96% heart rhythm: sr (sinus rhythm) wgt (current): 62.3 kg (admission): 66.3 kg cvp: 15 (10 - 20)mmhg total in: 2,925 ml 461 ml po: 770 ml tf: ivf: 2,155 ml 461 ml blood products: total out: 4,590 ml 2,040 ml urine: 4,590 ml 2,040 ml ng: stool: drains: balance: -1,665 ml -1,579 ml respiratory support o2 delivery device: nasal cannula spo2: 95% abg: ///24/ physical examination general appearance: no acute distress eyes / conjunctiva: conjunctiva pale head, ears, nose, throat: normocephalic cardiovascular: (s1: normal), (s2: normal), jvp to 14cm peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: doppler), (left dp pulse: doppler) respiratory / chest: (breath sounds: crackles : bibasilar) abdominal: soft, non-tender, bowel sounds present extremities: trace bilateral lower extremity edema, right knee with erythema, tenderness, and swelling musculoskeletal: muscle wasting skin: not assessed neurologic: attentive, follows simple commands, responds to: verbal stimuli, oriented (to): person, place, and time, movement: not assessed, tone: not assessed labs / radiology 137 k/ul 9.7 g/dl 120 mg/dl 4.1 mg/dl 24 meq/l 3.9 meq/l 100 mg/dl 103 meq/l 139 meq/l 28.3 % 7.8 k/ul [image002.jpg] [**2179-4-18**] 03:54 am [**2179-4-18**] 02:41 pm [**2179-4-19**] 04:27 am [**2179-4-19**] 04:26 pm [**2179-4-20**] 03:28 am wbc 5.2 8.1 7.8 hct 28.4 31.4 29.7 29.5 28.3 plt 90 124 137 cr 4.3 4.2 4.4 4.3 4.1 glucose 90 143 138 116 120 other labs: pt / ptt / inr:17.3/33.0/1.6, ca++:9.1 mg/dl, mg++:2.4 mg/dl, po4:4.9 mg/dl assessment and plan 79 yo with pmh of cad p/w hypotension x 6 weeks, guaiac positive stool, and arf. 1. acute on chronic systolic and diastolic biventricular heart failure leading to cardiogenic shock etiology of his acute worsening of his heart failure is unclear. differential includes persistent and worsening mitral regurgitation, although precipitant is unclear. [**name2 (ni) 6188**] were negative for clot. plan is the following: - continue milrinone for inotropic support with plan to wean after 3l negative today if off phenylephrine -phenylephrine to maintain peripheral tone, weans as tolerated to aim for map goal> 50 - continue lasix drip to maintain urine output with goal of 2-3l - consider adding metolazole 5mg [**hospital1 **] to achieve goal urine output -repeat echo in am 2. right knee effusion-patient has evidence of right knee effusion after falling at homewith exam findings consistent with inflammation, tapped yesterday with cell count not looking like septic joint. -continue cephalexin for now and consider broadening coverage if patient has any systemic signs of infection 3. acute kidney injury: feurea suggests pre-renal etiology which is likely poor forward from heart failure. creatinine improved today - continue heart failure treatment as described above, -trend creatinine, if oes not improve, consider renal consult 4. gib/ulcers: plan per micu note: hct stable from [**4-8**] [**location (un) 755**] stay. known gastric ulcers from [**location (un) 755**]. hct stable. -restart asa 81mg - t and s - 2 18g iv - ppi [**hospital1 7**] -check daily hct 5. ascites: suspect volume from chf. can trend lfts. 6. cad: last cath in [**2176**], no ck leak initially to suggest infarction and no symptoms of acs. can consider angiography to evaluate for graft failure or restenosis, but would defer for now given renal impairment. -hold beta blocker in the setting of low heart rate, will restart if hr>75 -continue asa, statin . 7. anemia: at recent baseline. see above re: gi bleed 8. pyuria: wbc [**7-21**]. asymptomatic. - culture finalized negative. 9. thrombocytopenia: ? [**3-15**] hepatic failure from right heart failure. also ? of mds per outpatient cardiologist. - follow # fen: no ivf, replete electrolytes, regular diet # prophylaxis: pneumoboots, ppi # access: 2 18g pivs # code: dnr/dni confirmed with patient # communication: patient icu care nutrition: glycemic control: lines: 18 gauge - [**2179-4-17**] 03:03 pm multi lumen - [**2179-4-18**] 11:29 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",0
276,"chief complaint: 24 hour events: wound culture - at [**2179-4-19**] 02:50 pm r knee tap -continued on lasix gtt with >100cc per hour uop, continued milrinone -still on neo at 10pm but maps high 50s, so have asked to wean. by am, have weaned down to 1.5 from 3 -code status confirmed with wife as dnr/dni per [**doctor first name 6208**]. -had knee tapped->not septic -ordered ambien for sleep (reportedly takes at home and had 2 nights ago with good effect, no adverse reaction) allergies: neomycin sulfate/hc (topical) unknown; unknown; beet unknown; last dose of antibiotics: infusions: milrinone - 0.5 mcg/kg/min phenylephrine - 1.5 mcg/kg/min furosemide (lasix) - 10 mg/hour other icu medications: other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2179-4-20**] 06:05 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.4 c (97.6 tcurrent: 36.1 c (97 hr: 72 (56 - 72) bpm bp: 104/79(85) {82/35(47) - 113/79(85)} mmhg rr: 26 (14 - 27) insp/min spo2: 96% heart rhythm: sr (sinus rhythm) wgt (current): 62.3 kg (admission): 66.3 kg cvp: 15 (10 - 20)mmhg total in: 2,925 ml 461 ml po: 770 ml tf: ivf: 2,155 ml 461 ml blood products: total out: 4,590 ml 2,040 ml urine: 4,590 ml 2,040 ml ng: stool: drains: balance: -1,665 ml -1,579 ml respiratory support o2 delivery device: nasal cannula spo2: 95% abg: ///24/ physical examination general appearance: no acute distress eyes / conjunctiva: conjunctiva pale head, ears, nose, throat: normocephalic cardiovascular: (s1: normal), (s2: normal), jvp to 14cm peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: doppler), (left dp pulse: doppler) respiratory / chest: (breath sounds: crackles : bibasilar) abdominal: soft, non-tender, bowel sounds present extremities: trace bilateral lower extremity edema, right knee with erythema, tenderness, and swelling musculoskeletal: muscle wasting skin: not assessed neurologic: attentive, follows simple commands, responds to: verbal stimuli, oriented (to): person, place, and time, movement: not assessed, tone: not assessed labs / radiology 137 k/ul 9.7 g/dl 120 mg/dl 4.1 mg/dl 24 meq/l 3.9 meq/l 100 mg/dl 103 meq/l 139 meq/l 28.3 % 7.8 k/ul [image002.jpg] [**2179-4-18**] 03:54 am [**2179-4-18**] 02:41 pm [**2179-4-19**] 04:27 am [**2179-4-19**] 04:26 pm [**2179-4-20**] 03:28 am wbc 5.2 8.1 7.8 hct 28.4 31.4 29.7 29.5 28.3 plt 90 124 137 cr 4.3 4.2 4.4 4.3 4.1 glucose 90 143 138 116 120 other labs: pt / ptt / inr:17.3/33.0/1.6, ca++:9.1 mg/dl, mg++:2.4 mg/dl, po4:4.9 mg/dl assessment and plan 79 yo with pmh of cad p/w hypotension x 6 weeks, guaiac positive stool, and arf. 1. acute on chronic systolic and diastolic biventricular heart failure leading to cardiogenic shock etiology of his acute worsening of his heart failure is unclear. differential includes persistent and worsening mitral regurgitation, although precipitant is unclear. [**name2 (ni) 6188**] were negative for clot. plan is the following: - continue milrinone for inotropic support with plan to wean after 3l negative today if off phenylephrine -phenylephrine to maintain peripheral tone, weans as tolerated to aim for map goal> 50 - continue lasix drip to maintain urine output with goal of 2-3l - consider adding metolazole 5mg [**hospital1 **] to achieve goal urine output -repeat echo in am 2. right knee effusion-patient has evidence of right knee effusion after falling at homewith exam findings consistent with inflammation, tapped yesterday with cell count not looking like septic joint. -continue cephalexin for now and consider broadening coverage if patient has any systemic signs of infection 3. acute kidney injury: feurea suggests pre-renal etiology which is likely poor forward from heart failure. creatinine improved today - continue heart failure treatment as described above, -trend creatinine, if oes not improve, consider renal consult 4. gib/ulcers: plan per micu note: hct stable from [**4-8**] [**location (un) 755**] stay. known gastric ulcers from [**location (un) 755**]. hct stable. -restart asa 81mg - t and s - 2 18g iv - ppi [**hospital1 7**] -check daily hct 5. ascites: suspect volume from chf. can trend lfts. 6. cad: last cath in [**2176**], no ck leak initially to suggest infarction and no symptoms of acs. can consider angiography to evaluate for graft failure or restenosis, but would defer for now given renal impairment. -hold beta blocker in the setting of low heart rate, will restart if hr>75 -continue asa, statin . 7. anemia: at recent baseline. see above re: gi bleed 8. pyuria: wbc [**7-21**]. asymptomatic. - culture finalized negative. 9. thrombocytopenia: ? [**3-15**] hepatic failure from right heart failure. also ? of mds per outpatient cardiologist. - follow # fen: no ivf, replete electrolytes, regular diet # prophylaxis: pneumoboots, ppi # access: 2 18g pivs # code: dnr/dni confirmed with patient # communication: patient icu care nutrition: glycemic control: lines: 18 gauge - [**2179-4-17**] 03:03 pm multi lumen - [**2179-4-18**] 11:29 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition: ------ protected section ------ diuresing well continue plans ------ protected section addendum entered by:[**name (ni) **] [**name (ni) **] on:[**2179-4-21**] 13:19 ------",0
277,"title: chief complaint: change in mental status 24 hour events: stool culture - at [**2178-2-11**] 04:16 pm c.diff sample blood cultured - at [**2178-2-11**] 04:30 pm cvl - vent set rate down to 16 -> abg 7.37/36/171 --> decreased rate further to 14 --> 7.35/39/148 - fentanyl/versed d/c'd and precedex started with bolus - tube feeding started-> residual 140cc, so held - id rejected iv vancomycin. last dose 8 pm [**2178-2-11**] - heme recs: cont. hydroxyurea, hold ifn, replace vit k allergies: sulfonamides unknown; a.c.e inhibitors angioedema; angiotensin receptor antagonist angioedema; keflex (oral) (cephalexin monohydrate) nausea/vomiting last dose of antibiotics: ceftriaxone - [**2178-2-9**] 10:30 pm acyclovir - [**2178-2-10**] 06:00 am ampicillin - [**2178-2-10**] 09:56 am ciprofloxacin - [**2178-2-10**] 10:00 pm metronidazole - [**2178-2-11**] 07:40 am vancomycin - [**2178-2-11**] 10:00 pm infusions: dexmedetomidine (precedex) - 0.4 mcg/kg/hour other icu medications: famotidine (pepcid) - [**2178-2-11**] 08:00 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2178-2-12**] 06:50 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.2 c (97.1 tcurrent: 35.7 c (96.2 hr: 90 (90 - 92) bpm bp: 102/49(68) {88/46(61) - 175/87(120)} mmhg rr: 15 (12 - 22) insp/min spo2: 100% heart rhythm: v paced cvp: 12 (6 - 16)mmhg total in: 1,333 ml 187 ml po: tf: 77 ml 60 ml ivf: 1,186 ml 126 ml blood products: total out: 960 ml 170 ml urine: 960 ml 170 ml ng: stool: drains: balance: 373 ml 17 ml los + 8l respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml vt (spontaneous): 616 (616 - 616) ml rr (set): 14 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi: 24 pip: 17 cmh2o plateau: 10 cmh2o compliance: 61.7 cmh2o/ml spo2: 100% abg: 7.37/39/148/23/-2 ve: 6.6 l/min pao2 / fio2: 370 physical examination general appearance: intubated. sedated, not following commands. eyes / conjunctiva: perrl head, ears, nose, throat: poor dentition cardiovascular: (s1: normal), (s2: normal), (murmur: systolic) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: diminished), (left dp pulse: diminished) respiratory / chest: diminished at bases bilaterally, otherwise clear abdominal: soft, bowel sounds present, distended, tenderness not able to assess extremities: right: absent, left: absent, no(t) cyanosis, no(t) clubbing neurologic: responds to: not assessed, oriented (to): self and place, movement: not assessed, tone: not assessed labs / radiology 232 k/ul 10.1 g/dl 105 mg/dl 1.1 mg/dl 23 meq/l 4.1 meq/l 24 mg/dl 114 meq/l 142 meq/l 33.2 % 34.9 k/ul [image002.jpg] [**2178-2-9**] 10:28 pm [**2178-2-10**] 01:56 am [**2178-2-10**] 06:32 am [**2178-2-10**] 03:24 pm [**2178-2-11**] 02:45 am [**2178-2-11**] 03:45 am [**2178-2-11**] 02:34 pm [**2178-2-11**] 06:38 pm [**2178-2-12**] 03:47 am [**2178-2-12**] 04:12 am wbc 27.0 18.8 25.2 34.9 hct 34.5 31.9 31.3 33.2 plt [**telephone/fax (3) 6270**]32 cr 1.3 1.2 1.2 1.1 tco2 23 23 21 22 22 23 glucose 117 105 100 105 other labs: pt / ptt / inr:16.4/33.7/1.5, ck:51, alt / ast:50/124, alk phos / t bili:156/0.6, lactic acid:0.9 mmol/l, albumin:2.6 g/dl, ldh:429 iu/l, mg++:2.5 mg/dl, po4:3.1 mg/dl; c. diff neg x 2 assessment and plan this is a 72m with septic shock and respiratory failure. . # respiratory failure: improving. on admission, pt was hypoxic to low 90s on non-rebreather thus was intubated. likely due to septic shock. pt does have h/o chronic pleural effusion r>l. rsbi 141 this am however during rounds, had little respiratory drive. had difficulty lifting sedation on fentanyl & versed due to periods of agitation. zyprexa had little effect; can t use haldol due to risk of qt prolongation (490ms at baseline). did much better overnight on precedex. tolerating minimal pressure support this morning. - attempt extubation today - follow abg . # septic shock/ fever: unclear source. top differentials include recurrent c. diff, ischemic bowel disease, pna. all microbiology studies have been negative to date. - to improve bp, limit sedation and give ivf boluses judiciously (give if cvp and uop also down). goal map>60-65, sbp>90. - if pressor requirement increases, consider adding vasopressin - ct torso showing colitis. c. diff neg x 2. given the high suspicion, will check again. continue po vanc for empiric therapy of c. diff. will stop iv flagyl ([**2-12**]). radiographic results could be changes related to his prior episodes of c. diff. additional stool studies still pending. - continue ceftriaxone for empiric coverage for pneumonia in the absence of microbiology data - if above investigations negative for source of infection, consider diagnostic [**female first name (un) 217**] for ?empyema (low suspicion though, since fluid is free flowing and chronic) . # steroids: cortstim 14.6->19.1. abnormal in the setting of acute illness. started hydrocort 100 mg q8 hrs [**2-10**]. will stop on [**2-12**] given overall improvement. # cardiac: trop leak in the setting of demand ischemia. cardiac cath 3 years ago at [**hospital1 609**] showed no flow limiting lesions per patient. echo done; no evidence of new areas of dysfunction - continue 325mg asa, simva - hold heparin for now as suspicion of demand ischemia is high and pt is already coagulopathic (inr 1.6) - will ask ep to decrease rate of pacemaker as acute illness resolving. . # change in mental status: pt has tendency to become delirious during acute illnesses; or may be a presenting symptom of meningitis. did much better on precedex than on fentanyl & versed. patient s prior episodes of agitation may be an adverse reaction to benzos. . # idiopathic myelofibrosis: pt s outpt hematologist visited pt informally - resume hydroxyurea; hold interferon . # chronic renal failure: at baseline, 1.1 - avoid nephrotoxins - follow cr . # paf with pacemaker: stable, rate well-controlled. v-paced at this time. - ep saw patient, adjusted settings to increase ventricular demand pacing to 90. will re-consult and ask to decrease rate as patient has improved. . # chf (ef of 45%): repeat echo showing stable ef. - hold lasix in the setting of hypotension . # h/o htn - hold home dose of toprol xl 25mg daily in the setting of hypotension - continue asa and simvastatin . # pvd: decreased pulses in lower extremities - hold pentoxyfilline for now . # coagulopathy: inr near 2. patient received vitamin k. inr now 1.5 - unclear etiology - site of rij oozing continuously -> will place a picc instead and pull the line and send tip for cx . # elevated liver enzymes; stable transaminases, t.bili improved - monitor lfts . # hypothyroidism: tsh is elevated but free t4 wnl. likely sick euthyroid in the setting of acute illness. - continue home dose synthroid . # fen: ivf prn, replete electrolytes, nutrition consult placed. tf held overnight due to residuals. will consider po diet post-extubation if ms improved. . # prophylaxis: pneumoboots, start hsq today as inr is now 1.6, h2 blocker. . # access: 1 piv, rij (place [**2178-2-9**]), a line (placed [**2178-2-9**]) . # code: full, confirmed with patient and his wife. . # communication: family; hcp is wife [**doctor first name 96**]: [**telephone/fax (1) 6184**]) . # disposition: icu for now icu care nutrition: glycemic control: lines: arterial line - [**2178-2-9**] 03:19 am multi lumen - [**2178-2-9**] 04:15 am prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition: ------ protected section ------ correction to access: patient had picc line placed today. a-line already removed. will remove ij once clear that patient is stable and will not require reintubation and pressors. ------ protected section addendum entered by:[**name (ni) 914**] [**last name (namepattern1) 3143**], md on:[**2178-2-12**] 14:31 ------ micu attending addendum i saw and examined the patient, and was physically present with the icu team for the key portions of the services provided. i agree with the note above, including the assessment and plan. i would emphasize and add the following points: 72m idiopathic myelofibrosis on ifn, af s/p ppm, ckd, dcm (45%), hypothyroidism, c. diff p/w fevers and altered mental status. off pressors; mental status doing well on precedex, tolerating psv. exam notable for tm 98.9 bp 118/60 hr 90/paced rr 22 with sat on vac 500*22 0.4 5, cvp 5-12, 7.43/30/207 tbb+5l/24h. responsive, overbreathing vent. coarse bs b. rrr s1s2. soft +bs. [**month (only) **] bs. tr edema. labs notable for wbc 35k, hct 33, k+ 4.1, cr 1.1. cxr with b asd. bal gs negative. agree with plan to manage sepsis / respiratory failure with ctx for pneumonia and po vanco for resolving c. diff. will continue psv and extubate while on precedex. creatinine is down slightly today; will dose meds to low ccr and avoid nephrotoxins; may need lasix post extubation. he ruled in for mi; will continue asa and continue to monitor while treating primary medical illness. for af, pacer demand rate increased to 90bpm on admission, can likely decrease soon. myelofibrosis present but stable, continue hydroxyurea. above d/w wife at bedside. remainder of plan as outlined above. patient is critically ill total time: 40 min ------ protected section addendum entered by:[**name (ni) 453**] [**last name (namepattern1) 775**], md on:[**2178-2-12**] 03:20 pm ------",1
278,"demographics day of intubation: day of mechanical ventilation: 3 ideal body weight: 54.4 none ideal tidal volume: 217.6 / 326.4 / 435.2 ml/kg airway airway placement data known difficult intubation: no procedure location: reason: tube type ett: position: 23 cm at teeth route: oral type: standard size: 7mm lung sounds rll lung sounds: diminished rul lung sounds: clear lul lung sounds: clear lll lung sounds: diminished comments: secretions sputum color / consistency: white / thin sputum source/amount: suctioned / small comments: ventilation assessment level of breathing assistance: visual assessment of breathing pattern: normal quiet breathing plan next 24-48 hours: continue with daily rsbi tests & sbt's as tolerated reason for continuing current ventilatory support: underlying illness not resolved respiratory care shift procedures bedside procedures: bronchoscopy (0830) comments: no plug seen or removed, bal sample of lll sent to lab. patient remains intubated and on mechanical ventilation, had therapeutic bronchoscopy done this morning, no mucus plug seen or removed, treated with combivent inhaler and 20% mucomyst instilled, no adverse reactions,spo2 remains upper 90s although fio2 was weaned from 50% to 35%, pressure support also weaned from 15 to 10, so far well tolerated , will be weaned and extubated later this evening or tomorrow morning.",0
279,"valve replacement, aortic bioprosthetic (avr) assessment: intubated/sedated. on ntg,milrinone,propofol gtts. hemodynamicallu stable. sv02=72% co/ci= 6.5/3.3 t-max 101.7 k+= 3.4 glucose=165/ 104/ 146 action: weaned milrinone to 0.25 mcgkgmin. weaned vent to cpap 40% 5/5. 650mg tyleneol via ogt x2. 20meq kcl iv x2. riss rotocol folled followed. response: remained stable with no adverse reactions to weaning. see assessment sheet. remains febrile @ 101.0 plan: continue to wean to extubate. monitor hemodynamics,labs. pain management",0
280,"[**age over 90 **] year-old male with pmh significant for htn, severe copd, cad ( s/p prior mi)who presents with new hypoxic episode with likely aspiration event in setting of hemoptysis vs. gi bleed .h/o respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: sedated with versed 2mg/hr and fentanyl 200mcg/hr vented on ac/40/500/18/5 lung sounds diminished t/o,sats 100%,suctioned small amt [**doctor last name 573**] tinged secretion abg 7.36/48/69 haemodinamically remains stable,cvp 15- 20 cm of h2o action: no vent changes overnight steroids and nebs continued response: remained stable on present vent settings plan: contune haemodinamic monitoring wean vent as tolerated follow up on culture data,ppd [**location (un) **] on airborne and contact precautions hemoptysis assessment: crit 30.1 on [**2199-8-6**] pm,not actively bleeding now inr 2.7 on [**2199-8-6**] has minimal [**date range 573**] tinged secretions via et action: prbc one unit transfuse over 2hrs without any adverse reactions ffp 2units,heparin on hold. cetral line inserted after [**date range 573**] products response: post transfusion crit 32.4 plan: moitor crit q6h transfuse for <30 hypotension (not shock) assessment: pt is known hypertensive on home meds,was hypotensive and oliguric at the beginning of the shift, central line inserted after the [**name6 (md) 573**] products md notified about the diminished urine output action: pt was fluid rescusitated at the beginning of the shift one unit prbc and 2units of ffp transfused antihypertensives on hold response: pt haemodinamically improved, urine output 30 ml/hr concentrated cvp 20 cm of h2o hold on fluid bolus plan: maintain uo 30 ml/hr follow up am labs for renal fuction.",0
281,"[**age over 90 **] year-old male with pmh significant for htn, severe copd, cad ( s/p prior mi)who presents with new hypoxic episode with likely aspiration event in setting of hemoptysis vs. gi bleed .h/o respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: sedated with versed 2mg/hr and fentanyl 200mcg/hr vented on ac/40/500/18/5 lung sounds diminished t/o,sats 100%,suctioned small amt [**doctor last name 573**] tinged secretion abg 7.29/54/63 haemodinamically remains stable,cvp 20 cm of h2o action: no vent changes overnight steroids and nebs continued response: remained stable on present vent settings plan: contune haemodinamic monitoring wean vent as tolerated follow up on culture data,ppd [**location (un) **] on airborne and contact precautions hemoptysis assessment: crit 30.1 on [**2199-8-6**] pm,not actively bleeding now inr 2.7 on [**2199-8-6**] has minimal [**date range 573**] tinged secretions via et action: prbc one unit transfuse over 2hrs without any adverse reactions ffp 2units,heparin on hold. cetral line inserted after [**date range 573**] products response: post transfusion crit 32.4 plan: moitor crit q6h transfuse for <30 hypotension (not shock) assessment: pt is known hypertensive on home meds,was hypotensive and oliguric at the beginning of the shift, central line inserted after the [**name6 (md) 573**] products md notified about the diminished urine output action: pt was fluid rescusitated at the beginning of the shift one unit prbc and 2units of ffp transfused antihypertensives on hold response: pt haemodinamically improved, urine output 30 ml/hr concentrated cvp 20 cm of h2o hold on fluid bolus plan: maintain uo 30 ml/hr follow up am labs for renal fuction.",0
282,"[**age over 90 **] year-old male with pmh significant for htn, severe copd, cad ( s/p prior mi)who presents with new hypoxic episode with likely aspiration event in setting of hemoptysis vs. gi bleed .h/o respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: sedated with versed 2mg/hr and fentanyl 200mcg/hr vented on ac/40/500/18/5 lung sounds diminished t/o,sats 100%,suctioned small amt blood tinged secretion abg 7.29/54/63 haemodinamically remains stable,cvp 20 cm of h2o action: no vent changes overnight steroids and nebs continued response: remained stable on present vent settings plan: contune haemodinamic monitoring wean vent as tolerated follow up on culture data,ppd [**location (un) **] on airborne and contact precautions hemoptysis assessment: crit 30.1 on [**2199-8-6**] pm,not actively bleeding now inr 2.7 on [**2199-8-6**] has minimal blood tinged secretions via et action: prbc one unit transfuse over 2hrs without any adverse reactions ffp 2units cetral line inserted after blood products response: post transfusion crit 32.4 plan: moitor crit q6h transfuse for <30",0
283,"[**age over 90 **] year-old male with pmh significant for htn, severe copd, cad ( s/p prior mi)who presents with new hypoxic episode with likely aspiration event in setting of hemoptysis vs. gi bleed .h/o respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: sedated with versed 2mg/hr and fentanyl 200mcg/hr vented on ac/40/500/18/5 lung sounds diminished t/o,sats 100%,suctioned small amt blood tinged secretion abg 7.29/54/63 action: no vent changes overnight steroids and nebs continued response: remained stable on present vent settings plan: contune haemodinamic monitoring wean vent as tolerted hemoptysis assessment: crit 30.1 on [**2199-8-6**] pm,not actively bleeding now inr has minimal blood tinged secretions via et action: prbc one unit transfuse over 2hrs without any adverse reactions ffp 2units cetral line inserted after blood products response: post transfusion crit 32.4 plan: moitor crit q6h transfuse for <30",0
284,"[**age over 90 **] year-old male with pmh significant for htn, severe copd, cad ( s/p prior mi)who presents with new hypoxic episode with likely aspiration event in setting of hemoptysis vs. gi bleed .h/o respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: sedated with versed 2mg/hr and fentanyl 200mcg/hr vented on ac/40/500/18/5 lung sounds diminished t/o,sats 100%,suctioned small amt blood tinged secretion abg 7.29/54/63 haemodinamically remains stable,cvp 20 cm of h2o action: no vent changes overnight steroids and nebs continued response: remained stable on present vent settings plan: contune haemodinamic monitoring wean vent as tolerted hemoptysis assessment: crit 30.1 on [**2199-8-6**] pm,not actively bleeding now inr 2.7 on [**2199-8-6**] has minimal blood tinged secretions via et action: prbc one unit transfuse over 2hrs without any adverse reactions ffp 2units cetral line inserted after blood products response: post transfusion crit 32.4 plan: moitor crit q6h transfuse for <30",0
285,"title: chief complaint: etoh withdrawal, c-spine fractures hpi: 69 yo male with a history of etoh abuse and neck arthritis who was transferred from [**hospital3 **] for cervical spine fractures s/p two falls over past 2 days. pt reported falling forward onto his forehead on 2 days ago and falling backward onto his neck in his bathtub yesterday with loss consciousness both times but did not seek medical attention. this am, he presented to the [**hospital3 **] ed for neck pain and was found to have odontoid and c4 fractures; he was transferred here for further management. in the ed, initial vs were: t 97.7, hr 106, bp 143/94, o2sat 96% on ra. pt alert and oriented with intact neurologic exam. mildly wheezy so given albuterol and ipratropium nebs x 2. patient was given morphine 2mg x 1 and 4mg x 2 for pain control. seen by ortho-spine who thought his c-spine fracture may have been acute on chronic per review of osh ct c-spine; recommended ct t- and l- spine with plan for surgery. in the meantime, pt reported feeling anxious and was given lorazepam 2mg iv per request. there was subsequently concern for etoh withdrawal given restlessness, tachycardia to 107, and sbp 180s-200s. pt admitted to drinking 1 quart of vodka nightly. given valium 10mg iv x 2. started on banana bag. serum and urine tox screens pending. admitted to micu for etoh withdrawal. on transfer, vs: t 97.9, hr 101, bp 153/48, rr 16, o2sat 100% nrb. on the floor, pt denies hallucinations or anxiety. no neck or back pain. per his sister, his last known drink was thursday night. no h/o etoh withdrawal in past (""never off alcohol long enough""), seizure disorder, psych disorder. no h/o cad or cva. no h/o neck fracture. patient admitted from: [**hospital1 19**] er history obtained from family / [**hospital 75**] medical records patient unable to provide history: uncooperative allergies: last dose of antibiotics: infusions: other icu medications: other medications: - unknown pain medication (?vicodin) past medical history: family history: social history: - etoh abuse - tobacco abuse - neck arthritis father d. 58 of colorectal cancer. mother d. 74 of copd, chf, smoker. 2 healthy sisters. [**name (ni) **] brother d. 26 of brain aneurysm. occupation: retired engineer for faa drugs: none per family tobacco: 1 ppd x 60 years alcohol: 1 quart vodka nightly other: lives alone, never married, no children. close relationship with sister/hcp who lives nearby. review of systems: constitutional: no(t) fever eyes: no(t) blurry vision, denies blurry vision cardiovascular: no(t) chest pain respiratory: no(t) cough, no(t) dyspnea, no(t) wheeze gastrointestinal: no(t) abdominal pain, no(t) nausea, no(t) emesis, no(t) diarrhea, no(t) constipation genitourinary: no(t) dysuria, foley musculoskeletal: no(t) joint pain, no(t) myalgias neurologic: no(t) numbness / tingling, no(t) headache, no(t) seizure psychiatric / sleep: agitated, denies hallucinations flowsheet data as of [**2166-7-26**] 02:50 pm vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.1 c (97 tcurrent: 36.1 c (97 hr: 95 (95 - 95) bpm rr: 20 (20 - 20) insp/min spo2: 97% heart rhythm: sr (sinus rhythm) height: 70 inch total in: 173 ml po: tf: ivf: 173 ml blood products: total out: 0 ml 235 ml urine: 235 ml ng: stool: drains: balance: 0 ml -62 ml respiratory o2 delivery device: non-rebreather spo2: 97% physical examination general appearance: well nourished, no acute distress, overweight / obese, agitated, not cooperative with most questioning eyes / conjunctiva: perrl head, ears, nose, throat: poor dentition, ng tube, abrasion over left forehead 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: (expansion: symmetric), (breath sounds: clear : , no(t) crackles : , no(t) wheezes : , no(t) rhonchorous: ), anteriorly abdominal: soft, non-tender, bowel sounds present, no(t) distended, obese extremities: right: absent, left: absent skin: not assessed neurologic: follows simple commands, responds to: verbal stimuli, oriented (to): ""hospital,"" exam limited by cooperation, movement: purposeful, tone: normal, cn ii-xii grossly intact. strength 5/5 in all extremities. toes downgoing on babinski. labs / radiology 173 16.1 119 0.6 15 25 104 3.8 142 47.4 9.8 [image002.jpg] other labs: pt / ptt / inr:13/27.2/1.1, ck / ckmb / troponin-t:[**2089-9-22**]/<0.01, differential-neuts:71.4, lymph:20.5, mono:7, eos:0.8 fluid analysis / other labs: pt 13, ptt 27.2, inr 1.1 na 142, k 3.8, cl 104, hco3 25, bun 15, cr 0.6, glu 119, an gap 13 ca, mg, phos pending ck [**2089**], mb 9, trop t <0.01 serum asa, etoh, acetmnphn, benzo, barb, tricyc pending urine benzos, barbs, opiates, cocaine, amphet, mthdne pending u/a pending imaging: osh ct head w/o contrast (dictated read here): no acute intracranial process. . osh ct c-spine w/o contrast (prelim read here): a transverse, type 2 odontoid fracture is somewhat corticated and of uncertain chronicity. however, there is also 7 mm posterior displacement of the c1/upper c2 complex on the body of c2. additional fracture of c4 body, left lamina and c3-4 anterior osteophyte complex appears more acute. there is distration and minimal posterior displacement of the superior fracture fragment, with resultant focal lordotic curvature of the c-spine. there is prevertebral soft tissue swelling, which suggest acuity. profuse, confluent anterior bridging osteophytosis is noted. posterior osteophytes cause mild-moderate canal stenosis. rec mri for eval of cord contusion and ligamentous involvement. ecg: sinus tachycardia at 103 bpm with pvcs, lafb, q wave in v1 and v2, no st-t wave changes; no prior available for comparison. assessment and plan 69 yo man with known h/o etoh abuse p/w to osh for neck pain s/p falls and transferred here for management of cervical spine fractures, now in etoh withdrawal. . # etoh withdrawal: pt with h/o etoh abuse. no h/o withdrawal. - valium 10mg iv prn for ciwa > 10 - complete banana bag, then daily mvi, thiamine, folate - monitor electrolytes; replete k, mg, phos, ca prn - keep npo - social work consult . # c-spine fractures: ct c-spine from osh with acute appearing c4 fracture with type 2 transverse odontoid fracture of uncertain chronicity in setting of recent falls. pt denies weakness or sensory loss; neuro exam nonfocal. - appreciate ortho-spine input - ct t/l spine - [**location (un) 1083**] j-collar in place - bedrest with log roll precautions - plan for surgery when medically cleared - keep npo; coags checked, active t&s . # s/p multiple falls: 2 falls in past 2 days with reported loc after. no h/o seizure disorder although possible in the setting of etoh withdrawal. more likely intoxicated at the time of fall however as known to be drinking thursday night. no h/o other drug use. no h/o cva. osh ct head with no evidence of intracranial process. no h/o cad or arrhythmia. first set of cardiac enzymes unremarkable for acs. ekg notable only for pvcs and lafb. - monitor neuro exam - ciwa scale as above - f/u serum and urine tox - f/u ct head final read - monitor on tele, ekg in am - cycle cardiac enzymes - replete lytes prn . # h/o tobacco use: wheezes on exam at admission, now resolved. [**month (only) 51**] have copd given extensive h/o smoking. - declined nicotine patch - albuterol and ipratropium nebs prn - wean off o2 as tolerated . # neck arthritis: - obtain records from pcp [**last name (namepattern4) **]: pain control icu care nutrition: comments: npo, iv fluids glycemic control: lines: 18 gauge - [**2166-7-26**] 01:08 pm 20 gauge - [**2166-7-26**] 01:09 pm prophylaxis: dvt: boots, sq uf heparin stress ulcer: vap: need for restraints reviewed comments: communication: family meeting held , icu consent signed comments: patient. hcp/sister [**name (ni) 1118**] [**name (ni) 8571**] (home [**telephone/fax (1) 8572**], cell [**telephone/fax (1) 8573**]) code status: full code (discussed with hcp) disposition: icu ------ protected section ------ pre-op risk assessment: mr. [**known lastname 8576**] is a 70 year old man with a pmh of etoh and tobacco abuse a/w etoh withdrawal and s/p falls complicated by c2 and c4 fractures awaiting posterior cervical spine fusion by ortho-spine. he reports moderate functional capacity and no family or personal history of adverse reaction to anesthesia. he is at low cardiac risk (abnormal ekg) for an urgent, intermediate risk procedure. - would recommend sedation with versed given benzodiazepine requirement for etoh withdrawal - no need to initiate beta blocker therapy - pt to be kept npo - will hold heparin in anticipation of or - t&c x 2 units prbc ------ protected section addendum entered by:[**name (ni) 586**] [**last name (namepattern1) 7347**], md on:[**2166-7-27**] 06:29 ------",1
286,"title: clinician: resident mr. [**known lastname 8576**] is a 70 year old man with a pmh of etoh and tobacco abuse a/w etoh withdrawal and s/p falls complicated by c2 and c4 fractures awaiting posterior cervical spine fusion by ortho-spine. he reports moderate functional capacity and no family or personal history of adverse reaction to anesthesia. he is at low cardiac risk (abnormal ekg) for an urgent, intermediate risk procedure. - would recommend sedation with versed given benzodiazepine requirement for etoh withdrawal - no need to initiate beta blocker therapy - pt to be kept npo - will hold heparin in anticipation of or - t&c x 2 units prbc total time spent: 10 minutes patient is critically ill. ------ protected section------ duplicate (see addendum to admit notet) ------ protected section error entered by:[**name (ni) 586**] [**last name (namepattern1) 7347**], md on:[**2166-7-27**] 06:30 ------",0
287,"[**age over 90 **] year-old male with pmh significant for htn, severe copd, cad ( s/p prior mi)who presents with new hypoxic episode with likely aspiration event in setting of hemoptysis vs. gi bleed .h/o respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: sedated with versed 2mg/hr and fentanyl 150mcg/hr vented on ac/40/500/18/5 lung sounds diminished t/o,sats 100%,suctioned small amt [**doctor last name 573**] tinged secretion abg 7.36/48/69 haemodinamically remains stable,cvp 15- 20 cm of h2o action: no vent changes overnight steroids and nebs continued response: remained stable on present vent settings plan: contune haemodinamic monitoring wean vent as tolerated follow up on culture data,ppd [**location (un) **] on airborne and contact precautions repeat abg at am and vent changes accordingly. hemoptysis assessment: crit 30.1 on [**2199-8-6**] pm,not actively bleeding now inr 2.7 on [**2199-8-6**] has minimal [**date range 573**] tinged secretions via et action: prbc one unit transfuse over 2hrs without any adverse reactions ffp 2units,heparin on hold. cetral line inserted after [**date range 573**] products response: post transfusion crit 32.4 plan: moitor crit q6h transfuse for <30 hypotension (not shock) assessment: pt is known hypertensive on home meds,was hypotensive and oliguric at the beginning of the shift, central line inserted after the [**name6 (md) 573**] products md notified about the diminished urine output abp 93/32 at 0600 action: pt was given total of 2 ns at previous shift one unit prbc and 2units of ffp transfused antihypertensives on hold ns 500 ml bolused. response: pt haemodinamically improved, urine output 30 ml/hr concentrated cvp 20 cm of h2o hold on fluid bolus plan: maintain uo 30 ml/hr follow up am labs for renal fuction.",0
288,"title: clinician: resident mr. [**known lastname 8576**] is a 70 year old man with a pmh of etoh and tobacco abuse a/w etoh withdrawal and s/p falls complicated by c2 and c4 fractures awaiting posterior cervical spine fusion by ortho-spine. he reports moderate functional capacity and no family or personal history of adverse reaction to anesthesia. he is at low cardiac risk (abnormal ekg) for an urgent, intermediate risk procedure. - would recommend sedation with versed given benzodiazepine requirement for etoh withdrawal - no need to initiate beta blocker therapy - pt to be kept npo - will hold heparin in anticipation of or - t&c x 2 units prbc total time spent: 10 minutes patient is critically ill.",0
289,"title: clinician: resident mr. [**known lastname 8576**] is a 70 year old man with a pmh of etoh and tobacco abuse a/w etoh withdrawal and s/p falls complicated by c2 and c4 fractures awaiting posterior cervical spine fusion by ortho-spine. he reports moderate functional capacity and no family or personal history of adverse reaction to anesthesia. he is at low cardiac risk (abnormal ekg) for an urgent, intermediate risk procedure. - would recommend sedation with versed given benzodiazepine requirement for etoh withdrawal - no need to initiate beta blocker therapy - pt to be kept npo - will hold heparin in anticipation of or - t&c x 2 units prbc total time spent: 10 minutes patient is critically ill.",0
290,"[**age over 90 **] year-old male with pmh significant for htn, severe copd, cad ( s/p prior mi)who presents with new hypoxic episode with likely aspiration event in setting of hemoptysis vs. gi bleed .h/o respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: sedated with versed 2mg/hr and fentanyl 200mcg/hr vented on ac/40/500/18/5 lung sounds diminished t/o,sats 100%,suctioned small amt [**doctor last name 573**] tinged secretion abg 7.29/54/63 haemodinamically remains stable,cvp 20 cm of h2o action: no vent changes overnight steroids and nebs continued response: remained stable on present vent settings plan: contune haemodinamic monitoring wean vent as tolerated follow up on culture data,ppd [**location (un) **] on airborne and contact precautions hemoptysis assessment: crit 30.1 on [**2199-8-6**] pm,not actively bleeding now inr 2.7 on [**2199-8-6**] has minimal [**date range 573**] tinged secretions via et action: prbc one unit transfuse over 2hrs without any adverse reactions ffp 2units cetral line inserted after [**date range 573**] products response: post transfusion crit 32.4 plan: moitor crit q6h transfuse for <30 hypotension (not shock) assessment: pt is known hypertensive on home meds,was hypotensive and oliguric at the beginning of the shift, central line inserted after the [**name6 (md) 573**] products md notified about the diminished urine output action: pt was fluid rescusitated at the beginning of the shift one unit prbc and 2units of ffp transfused response: pt haemodinamically improved, urine output 30 ml/hr concentrated cvp 20 cm of h2o hold on fluid bolus plan: maintain uo 30 ml/hr follow up am labs for renal fuction.",0
291,"chief complaint: 24 hour events: -cooling protocol discontinued as deemed unnecessary -hct dropped, og lavage no gross blood, gastrooccult +, guaiac negative- yellow stool in rectal vault -id approval obtained for abx allergies: last dose of antibiotics: cefipime - [**2129-5-21**] 09:42 pm daptomycin - [**2129-5-22**] 12:15 am metronidazole - [**2129-5-22**] 04:00 am vancomycin - [**2129-5-22**] 05:00 am infusions: midazolam (versed) - 4 mg/hour fentanyl - 25 mcg/hour other icu medications: heparin sodium (prophylaxis) - [**2129-5-22**] 12:00 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2129-5-22**] 07:03 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.7 c (99.9 tcurrent: 37.7 c (99.9 hr: 74 (68 - 91) bpm bp: 110/54(72) {97/54(67) - 116/67(84)} mmhg rr: 14 (13 - 17) insp/min spo2: 100% heart rhythm: sr (sinus rhythm) cvp: 10 (6 - 10)mmhg total in: 220 ml 1,266 ml po: tf: ivf: 220 ml 1,266 ml blood products: total out: 205 ml 250 ml urine: 205 ml 250 ml ng: stool: drains: balance: 15 ml 1,016 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cpap/psv vt (set): 650 (650 - 650) ml rr (set): 14 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi: 40 pip: 23 cmh2o plateau: 16 cmh2o compliance: 59.1 cmh2o/ml spo2: 100% abg: 7.31/29/115/15/-10 ve: 12.3 l/min pao2 / fio2: 287 physical examination vital signs: hr 69 bp 108/81 rr 14 o2 100% on ac 550 x 18, peep 5, fio2 50% gen: nad, intubated, sedated heent: pupils small, perrl, + corneals, withdraws to pain chest: ctab cv: rrr, no m/r/g abd: soft, nt, nd, no masses or organomegaly ext: wwp, no c/c/e neuro: cooled, intubated, sedated, perrl, + corneals, withdraws to pain derm: no rashes labs / radiology 297 k/ul 6.9 g/dl 71 mg/dl 1.1 mg/dl 15 meq/l 3.3 meq/l 11 mg/dl 122 meq/l 144 meq/l 22.1 % 7.2 k/ul [image002.jpg] [**2129-5-21**] 07:53 pm [**2129-5-21**] 08:23 pm [**2129-5-21**] 11:13 pm [**2129-5-22**] 04:31 am [**2129-5-22**] 04:42 am [**2129-5-22**] 06:45 am wbc 9.0 7.2 hct 23.1 22.6 22.1 plt 316 297 cr 1.2 1.1 tropt 0.07 0.06 tco2 17 17 15 glucose 166 71 other labs: pt / ptt / inr:16.0/36.3/1.4, ck / ckmb / troponin-t:31//0.06, differential-neuts:80.1 %, lymph:16.7 %, mono:2.9 %, eos:0.2 %, lactic acid:0.8 mmol/l, albumin:1.8 g/dl, ca++:7.4 mg/dl, mg++:1.4 mg/dl, po4:2.6 mg/dl assessment and plan 73 yom w/ a h/o pvd, dm, cad and recent c diff presenting with pea arrest following 4 days of general malaise. # arrest: pea arrest. unclear etiology but recent admission for c diff and vre / s epi bactermia (all picc line related with negative surveillance cultures) ddx includes infection (sepsis, c diff), dehydration, gi bleed (as has history of pud, unlikely given hct 32, guaiac negative), pe (prelim cta negative for pe, has ivc filter for h/o dvt), mi (first set of ce relatively negative), no major electrolyte abnormalities (except mg of 1.3). -low gcs so started on cooling protocol, continue cooling unless adverse reaction, monitor for electrolyte abnormalities and for bleeding / worsening of infection -treat sepsis with daptomycin, cefepime and po vancomycin / iv flagyl, send cvo2, monitor cvp and maps -culture blood, urine, sputum, f/u cxr -monitor for signs of bleeding, continue on [**hospital1 **] ppi (home medication) -f/u final cta chest and ct abd/pelvis read -send tox screen -48 hour eeg per cooling protocol, if seizure then benzo and neuro consult -monitor electrolytes, glucose while on cooling protocol, avoid hyperthermia 24 hours after rewarming. -lactic acidosis- lactate trended to normal, monitor bp and uop # anemia: likely acute blood loss as he has gastoccult positive ng lavage. no rp bleed on ct torso yesterday. history of esophageal and stomach ulcers. gi wanted repeat egd in 6 weeks in early [**month (only) 51**]. also had colonoscopy with blood seen but no actively bleeding lesion. also, likely component of dehydraiton/volume contraction at admission, and drop in hct may be related to hydration. -trend hematocrit # respiratory: on ventilatory [**1-3**] arrest. -attempt to wean settings, oxygenating very well and currently being slightly overventilated # etoh abuse: per old notes had drank 4oz of vodka per day -versed for sedation, will give bolus versed vs. valium for tachycardia / hypertension -thiamine iv, folate, mvi daily # ?bilateral renal infarcts: f/u final read -trend cr, currently 1.6 (baseline 1.5 - 2.0) -no other signs of infarction -continue abx -obtain echo to evaluate for vegetations if in fact are bilateral renal infarcts # cad: h/o mi in [**2120**], s/p stent at that time -ekg in a.m. -trend cardiac enzymes -asa 325mg in er, had been on aspirin in the past but this was held due to a massive gi bleedin in [**2129-3-2**]. will hold off on asa unless he rules in for mi -continue lipitor and beta blocker (home dose is low dose lopressor 12.5mg po bid) -no previous echo in system # dm: -hiss, last a1c was 6% in [**7-9**] # copd: standing inhaler q6hrs (albuterol and atrovent) fen: ivfs / replete lytes prn / npo / og tube ppx: sq heparin tid, bowel regimen prn, [**hospital1 **] ppi (home medication) access: piv's code status: full emergency contact: disposition: icu pending resolution of above icu care nutrition: glycemic control: lines: arterial line - [**2129-5-21**] 07:00 pm multi lumen - [**2129-5-21**] 07:02 pm prophylaxis: dvt: boots, sq uf heparin stress ulcer: ppi vap: comments: communication: comments: code status: full code disposition:icu",1
292,"chief complaint: s/p arrest hpi: 73 yom w/ a h/o dm, recent h/o diabetic foot ulcer / osteo, recent c diff infection, pud, presenting following an arrest. the patient called ems on the day of admission not feeling well. ems arrived and during transport the patient reportedly lost his pulse, cpr was initiated, aed with ""no shock advised"" and with cpr alone the patient regained his pulse prior to arriving at the hospital. per the son the patient has been fatigued, dehydrated, having persistent diarrhea which he states was unresponsive to the flagyl he was taking, had decreased urine output for 4 days. he had decreased po intake x 2 days and slight nausea. no vomiting but dry heaves x 1. no abdominal pain, no chest pain, shortness of breath. no focal weakness. no other complaints per son. also per the son the patient has a h/o etoh abuse, but the patient has told his son he has not drank for 60 days. however, the son states that he often lies about his drinking. . in the er his initial vs were: t 100.2, hr 123, bp 145/93 rr 14 o2 95% the patient underwent an ij placement and given 4l ivf. he was intubated and sedated. he withdrew to painful stimuli. given low gcs and reperfusion after arrest he was started on the cooling protocol. guaiac negative in the er. also given vanc, levofloxacin and flagyl. of note the patient had a recent admission to the medicine floor for recurrent c diff as well as vre and coag negative staph bacteremia (presumed picc line infection). his c diff was treated with po flagyl with a course to continue until [**2129-5-25**] (as he would stop dapto for vre on [**2129-5-18**]. his vre had grown from picc line cultures (1/2 bottles) from [**2129-5-2**] and his picc line was pulled, he had no + peripheral blood cultures, he started dapto on [**2129-5-5**]. in addition on [**5-3**] he had coag negative staph from picc line 1/4 bottles. the patient was discharged to rehab on [**5-6**], he stayed for 4 days and signed out ama. he only rec'd 5 days of daptomycin iv. he reportedly was continuing to take his po flagyl. patient admitted from: [**hospital1 19**] er allergies: last dose of antibiotics: infusions: other icu medications: other medications: atorvastatin 20 mg po daily trazodone 25mg po qhs multivitamin po daily alum-mag hydroxide-simeth 200-200-20 mg/5 ml 15-30ml po qid b-complex with vitamin c po daily sucralfate 1 gram po qid heparin 5000 units sc tid acetaminophen prn pantoprazole 40 mg po q12 hours metoprolol tartrate 12.5mg po bid metronidazole 500 mg po q8hrs calcium carbonate 500 mg po qid ferrous sulfate 325 mg po daily past medical history: family history: social history: 1. cad: s/p mi in [**2120**] w/ stent (aspirin stopped [**3-10**] due to massive gib) 2. cri: baseline cr 1.5-2.2 3. pud with massive gi bleed [**3-10**] requiring 10 units prbcs. pt underwent egd showing esophageal and stomach ulcers. colonoscopy with diverticulosis. pt was unable to swallow a capsule for capsule study. tagged rbc scan no source of active bleeding. 4. chronic r foot ulcerations/infections: s/p r metatarsal head resection on [**2125-12-13**], followed by podiatry 5. dm 2: c/b neuropathy, nephropathy, and chronic r foot infections. h/o microalbuminuria 6. h/o dvt w/ l filter 7. pvd 8. h/o squamous cell ca of left posterior auricular area (s/p removal by derm) 9. etoh abuse w/ alcoholic hepatitis 10. h/o cva [**2122**] with residual left foot weakness; mri in [**2125**] likely small acute cortical infarcts involving the right frontal lobe. extensive chronic small vessel infarcts. old right cerebellar infarct. 11. odontoid fracture in [**2125**] with traumatic horner syndrome l dm-mother, stroke-mother, [**name (ni) 7180**] occupation: drugs: tobacco: alcohol: other: pt denies etoh use for past 80 days. previously drank 4 oz of vodka every night, 2ppd x60 years, retired builder. patient has never had dts, seizures, or passed out as a result of drinking. he left rehab facility against medical advice and states he lives alone. takes medications on his own with assistance of his visiting nurse. patient has assistance from a woman who lives upstairs in his building who checks in once a day. does not speak with his son who was previously involved in his care. per previous notes patient does not want son [**name (ni) 167**] as his son ""wants him in a nursing home."" review of systems: flowsheet data as of [**2129-5-21**] 07:34 pm vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 0.9 c (33.7 tcurrent: 0.9 c (33.7 bp: 108/81(87) {108/81(87) - 108/81(87)} mmhg rr: 13 (13 - 13) insp/min spo2: 99% heart rhythm: sr (sinus rhythm) total in: po: tf: ivf: blood products: total out: 0 ml 0 ml urine: ng: stool: drains: balance: 0 ml 0 ml respiratory o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 650 (650 - 650) ml rr (set): 14 rr (spontaneous): 3 peep: 5 cmh2o fio2: 50% pip: 23 cmh2o plateau: 11 cmh2o spo2: 99% ve: 11.1 l/min physical examination vital signs: hr 69 bp 108/81 rr 14 o2 100% on ac 550 x 18, peep 5, fio2 50% gen: nad, intubated, sedated heent: pupils small, perrl, + corneals, withdraws to pain chest: ctab cv: rrr, no m/r/g abd: soft, nt, nd, no masses or organomegaly ext: wwp, no c/c/e neuro: cooled, intubated, sedated, perrl, + corneals, withdraws to pain derm: no rashes labs / radiology [image002.jpg] imaging: ct head [**2129-5-21**]: no acute intracranial hemorrhage ct abd / pelvis w/ contrast, cta chest [**2129-5-21**]: striated appearance of both kidneys with stranding, concerning for renal infarcts given provided history. no pe or dissection. severe emphysema in the lungs. cxr [**2129-5-21**]: extensive chronic appearing interstitial disease. tubes in appropriate position. please correlate with cta chest performed subsequently. cxr [**2129-5-21**] post line plcmt: in comparison with the earlier study of this date, there has been placement of a right internal jugular catheter that extends to the upper portion of the svc. no evidence of pneumothorax or change from prior study. microbiology: blood culture x 2 [**2129-5-21**]: pending c diff + on [**2129-5-4**] blood culture [**5-3**]: 1/2 bottles s epi catheter tip iv (picc line)- negative blood culture [**2129-5-2**]: vre 1/2 bottles. u/a [**2129-5-21**]: 0-2 wbc, mod bacteria, trace leuk esterase, neg nitrites, [**5-11**] hyaline casts. ecg: ekg: sinus tach rate 110, lad lafb, normal intervals, incomplete rbbb, lae, no new q waves, early r wave progression, no st t wave changes. no significant changes from prior [**3-10**]. assessment and plan 73 yom w/ a h/o pvd, dm, cad and recent c diff presenting with pea arrest following 4 days of general malaise. # arrest: pea arrest. unclear etiology but recent admission for c diff and vre / s epi bactermia (all picc line related with negative surveillance cultures) ddx includes infection (sepsis, c diff), dehydration, gi bleed (as has history of pud, unlikely given hct 32, guaiac negative), pe (prelim cta negative for pe, has ivc filter for h/o dvt), mi (first set of ce relatively negative), no major electrolyte abnormalities (except mg of 1.3). -low gcs so started on cooling protocol, continue cooling unless adverse reaction, monitor for electrolyte abnormalities and for bleeding / worsening of infection -treat sepsis with daptomycin, cefepime and po vancomycin / iv flagyl, send cvo2, monitor cvp and maps -culture blood, urine, sputum, f/u cxr -monitor for signs of bleeding, continue on [**hospital1 **] ppi (home medication) -f/u final cta chest and ct abd/pelvis read -send tox screen -48 hour eeg per cooling protocol, if seizure then benzo and neuro consult -monitor electrolytes, glucose while on cooling protocol, avoid hyperthermia 24 hours after rewarming. -lactic acidosis- lactate trended to normal, monitor bp and uop # respiratory: on ventilatory [**1-3**] arrest. -attempt to wean settings, oxygenating very well and currently being slightly overventilated # etoh abuse: per old notes had drank 4oz of vodka per day -versed for sedation, will give bolus versed vs. valium for tachycardia / hypertension -thiamine iv, folate, mvi daily # ?bilateral renal infarcts: f/u final read -trend cr, currently 1.6 (baseline 1.5 - 2.0) -no other signs of infarction -continue abx -obtain echo to evaluate for vegetations if in fact are bilateral renal infarcts # cad: h/o mi in [**2120**], s/p stent at that time -ekg in a.m. -trend cardiac enzymes -asa 325mg in er, had been on aspirin in the past but this was held due to a massive gi bleedin in [**2129-3-2**]. will hold off on asa unless he rules in for mi -continue lipitor and beta blocker (home dose is low dose lopressor 12.5mg po bid) -no previous echo in system # dm: -hiss, last a1c was 6% in [**7-9**] # copd: standing inhaler q6hrs (albuterol and atrovent) fen: ivfs / replete lytes prn / npo / og tube ppx: sq heparin tid, bowel regimen prn, [**hospital1 **] ppi (home medication) access: piv's code status: full emergency contact: disposition: icu pending resolution of above icu care nutrition: glycemic control: lines: multi lumen - [**2129-5-21**] 07:02 pm prophylaxis: dvt: boots, sq uf heparin stress ulcer: ppi vap: comments: communication: comments: code status: full code disposition:",1
293,"chief complaint: 24 hour events: -cooling protocol discontinued as deemed unnecessary -hct dropped, og lavage no gross blood, gastrooccult +, guaiac negative- yellow stool in rectal vault -id approval obtained for abx allergies: last dose of antibiotics: cefipime - [**2129-5-21**] 09:42 pm daptomycin - [**2129-5-22**] 12:15 am metronidazole - [**2129-5-22**] 04:00 am vancomycin - [**2129-5-22**] 05:00 am infusions: midazolam (versed) - 4 mg/hour fentanyl - 25 mcg/hour other icu medications: heparin sodium (prophylaxis) - [**2129-5-22**] 12:00 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2129-5-22**] 07:03 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.7 c (99.9 tcurrent: 37.7 c (99.9 hr: 74 (68 - 91) bpm bp: 110/54(72) {97/54(67) - 116/67(84)} mmhg rr: 14 (13 - 17) insp/min spo2: 100% heart rhythm: sr (sinus rhythm) cvp: 10 (6 - 10)mmhg total in: 220 ml 1,266 ml po: tf: ivf: 220 ml 1,266 ml blood products: total out: 205 ml 250 ml urine: 205 ml 250 ml ng: stool: drains: balance: 15 ml 1,016 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cpap/psv vt (set): 650 (650 - 650) ml rr (set): 14 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi: 40 pip: 23 cmh2o plateau: 16 cmh2o compliance: 59.1 cmh2o/ml spo2: 100% abg: 7.31/29/115/15/-10 ve: 12.3 l/min pao2 / fio2: 287 physical examination peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) skin: not assessed neurologic: responds to: not assessed, movement: not assessed, tone: not assessed labs / radiology 297 k/ul 6.9 g/dl 71 mg/dl 1.1 mg/dl 15 meq/l 3.3 meq/l 11 mg/dl 122 meq/l 144 meq/l 22.1 % 7.2 k/ul [image002.jpg] [**2129-5-21**] 07:53 pm [**2129-5-21**] 08:23 pm [**2129-5-21**] 11:13 pm [**2129-5-22**] 04:31 am [**2129-5-22**] 04:42 am [**2129-5-22**] 06:45 am wbc 9.0 7.2 hct 23.1 22.6 22.1 plt 316 297 cr 1.2 1.1 tropt 0.07 0.06 tco2 17 17 15 glucose 166 71 other labs: pt / ptt / inr:16.0/36.3/1.4, ck / ckmb / troponin-t:31//0.06, differential-neuts:80.1 %, lymph:16.7 %, mono:2.9 %, eos:0.2 %, lactic acid:0.8 mmol/l, albumin:1.8 g/dl, ca++:7.4 mg/dl, mg++:1.4 mg/dl, po4:2.6 mg/dl assessment and plan 73 yom w/ a h/o pvd, dm, cad and recent c diff presenting with pea arrest following 4 days of general malaise. # arrest: pea arrest. unclear etiology but recent admission for c diff and vre / s epi bactermia (all picc line related with negative surveillance cultures) ddx includes infection (sepsis, c diff), dehydration, gi bleed (as has history of pud, unlikely given hct 32, guaiac negative), pe (prelim cta negative for pe, has ivc filter for h/o dvt), mi (first set of ce relatively negative), no major electrolyte abnormalities (except mg of 1.3). -low gcs so started on cooling protocol, continue cooling unless adverse reaction, monitor for electrolyte abnormalities and for bleeding / worsening of infection -treat sepsis with daptomycin, cefepime and po vancomycin / iv flagyl, send cvo2, monitor cvp and maps -culture blood, urine, sputum, f/u cxr -monitor for signs of bleeding, continue on [**hospital1 **] ppi (home medication) -f/u final cta chest and ct abd/pelvis read -send tox screen -48 hour eeg per cooling protocol, if seizure then benzo and neuro consult -monitor electrolytes, glucose while on cooling protocol, avoid hyperthermia 24 hours after rewarming. -lactic acidosis- lactate trended to normal, monitor bp and uop # respiratory: on ventilatory [**1-3**] arrest. -attempt to wean settings, oxygenating very well and currently being slightly overventilated # etoh abuse: per old notes had drank 4oz of vodka per day -versed for sedation, will give bolus versed vs. valium for tachycardia / hypertension -thiamine iv, folate, mvi daily # ?bilateral renal infarcts: f/u final read -trend cr, currently 1.6 (baseline 1.5 - 2.0) -no other signs of infarction -continue abx -obtain echo to evaluate for vegetations if in fact are bilateral renal infarcts # cad: h/o mi in [**2120**], s/p stent at that time -ekg in a.m. -trend cardiac enzymes -asa 325mg in er, had been on aspirin in the past but this was held due to a massive gi bleedin in [**2129-3-2**]. will hold off on asa unless he rules in for mi -continue lipitor and beta blocker (home dose is low dose lopressor 12.5mg po bid) -no previous echo in system # dm: -hiss, last a1c was 6% in [**7-9**] # copd: standing inhaler q6hrs (albuterol and atrovent) fen: ivfs / replete lytes prn / npo / og tube ppx: sq heparin tid, bowel regimen prn, [**hospital1 **] ppi (home medication) access: piv's code status: full emergency contact: disposition: icu pending resolution of above icu care nutrition: glycemic control: lines: arterial line - [**2129-5-21**] 07:00 pm multi lumen - [**2129-5-21**] 07:02 pm prophylaxis: dvt: boots, sq uf heparin stress ulcer: ppi vap: comments: communication: comments: code status: full code disposition:icu",1
294,"chief complaint: 24 hour events: -cooling protocol discontinued as deemed unnecessary -hct dropped, og lavage no gross blood, gastrooccult +, guaiac negative- yellow stool in rectal vault -id approval obtained for abx allergies: last dose of antibiotics: cefipime - [**2129-5-21**] 09:42 pm daptomycin - [**2129-5-22**] 12:15 am metronidazole - [**2129-5-22**] 04:00 am vancomycin - [**2129-5-22**] 05:00 am infusions: midazolam (versed) - 4 mg/hour fentanyl - 25 mcg/hour other icu medications: heparin sodium (prophylaxis) - [**2129-5-22**] 12:00 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2129-5-22**] 07:03 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.7 c (99.9 tcurrent: 37.7 c (99.9 hr: 74 (68 - 91) bpm bp: 110/54(72) {97/54(67) - 116/67(84)} mmhg rr: 14 (13 - 17) insp/min spo2: 100% heart rhythm: sr (sinus rhythm) cvp: 10 (6 - 10)mmhg total in: 220 ml 1,266 ml po: tf: ivf: 220 ml 1,266 ml blood products: total out: 205 ml 250 ml urine: 205 ml 250 ml ng: stool: drains: balance: 15 ml 1,016 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cpap/psv vt (set): 650 (650 - 650) ml rr (set): 14 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi: 40 pip: 23 cmh2o plateau: 16 cmh2o compliance: 59.1 cmh2o/ml spo2: 100% abg: 7.31/29/115/15/-10 ve: 12.3 l/min pao2 / fio2: 287 physical examination vital signs: hr 69 bp 108/81 rr 14 o2 100% on ac 550 x 18, peep 5, fio2 50% gen: nad, intubated, sedated heent: pupils small, perrl, + corneals, withdraws to pain chest: ctab cv: rrr, no m/r/g abd: soft, nt, nd, no masses or organomegaly ext: wwp, no c/c/e neuro: cooled, intubated, sedated, perrl, + corneals, withdraws to pain derm: no rashes labs / radiology 297 k/ul 6.9 g/dl 71 mg/dl 1.1 mg/dl 15 meq/l 3.3 meq/l 11 mg/dl 122 meq/l 144 meq/l 22.1 % 7.2 k/ul [image002.jpg] [**2129-5-21**] 07:53 pm [**2129-5-21**] 08:23 pm [**2129-5-21**] 11:13 pm [**2129-5-22**] 04:31 am [**2129-5-22**] 04:42 am [**2129-5-22**] 06:45 am wbc 9.0 7.2 hct 23.1 22.6 22.1 plt 316 297 cr 1.2 1.1 tropt 0.07 0.06 tco2 17 17 15 glucose 166 71 other labs: pt / ptt / inr:16.0/36.3/1.4, ck / ckmb / troponin-t:31//0.06, differential-neuts:80.1 %, lymph:16.7 %, mono:2.9 %, eos:0.2 %, lactic acid:0.8 mmol/l, albumin:1.8 g/dl, ca++:7.4 mg/dl, mg++:1.4 mg/dl, po4:2.6 mg/dl assessment and plan 73 yom w/ a h/o pvd, dm, cad and recent c diff presenting with pea arrest following 4 days of general malaise. # arrest: pea arrest. unclear etiology but recent admission for c diff and vre / s epi bactermia (all picc line related with negative surveillance cultures) ddx includes infection (sepsis, c diff), dehydration, gi bleed (as has history of pud, unlikely given hct 32, guaiac negative), pe (prelim cta negative for pe, has ivc filter for h/o dvt), mi (first set of ce relatively negative), no major electrolyte abnormalities (except mg of 1.3). -low gcs so started on cooling protocol, continue cooling unless adverse reaction, monitor for electrolyte abnormalities and for bleeding / worsening of infection -treat sepsis with daptomycin, cefepime and po vancomycin / iv flagyl, send cvo2, monitor cvp and maps -culture blood, urine, sputum, f/u cxr -monitor for signs of bleeding, continue on [**hospital1 **] ppi (home medication) -f/u final cta chest and ct abd/pelvis read -send tox screen -48 hour eeg per cooling protocol, if seizure then benzo and neuro consult -monitor electrolytes, glucose while on cooling protocol, avoid hyperthermia 24 hours after rewarming. -lactic acidosis- lactate trended to normal, monitor bp and uop # respiratory: on ventilatory [**1-3**] arrest. -attempt to wean settings, oxygenating very well and currently being slightly overventilated # etoh abuse: per old notes had drank 4oz of vodka per day -versed for sedation, will give bolus versed vs. valium for tachycardia / hypertension -thiamine iv, folate, mvi daily # ?bilateral renal infarcts: f/u final read -trend cr, currently 1.6 (baseline 1.5 - 2.0) -no other signs of infarction -continue abx -obtain echo to evaluate for vegetations if in fact are bilateral renal infarcts # cad: h/o mi in [**2120**], s/p stent at that time -ekg in a.m. -trend cardiac enzymes -asa 325mg in er, had been on aspirin in the past but this was held due to a massive gi bleedin in [**2129-3-2**]. will hold off on asa unless he rules in for mi -continue lipitor and beta blocker (home dose is low dose lopressor 12.5mg po bid) -no previous echo in system # dm: -hiss, last a1c was 6% in [**7-9**] # copd: standing inhaler q6hrs (albuterol and atrovent) fen: ivfs / replete lytes prn / npo / og tube ppx: sq heparin tid, bowel regimen prn, [**hospital1 **] ppi (home medication) access: piv's code status: full emergency contact: disposition: icu pending resolution of above icu care nutrition: glycemic control: lines: arterial line - [**2129-5-21**] 07:00 pm multi lumen - [**2129-5-21**] 07:02 pm prophylaxis: dvt: boots, sq uf heparin stress ulcer: ppi vap: comments: communication: comments: code status: full code disposition:icu",1
295,"48 yr old hiv+ man transferred w/pcp pneumonia from 11r. here for bactrim desensitization. had pancreatitis in past from bactrim. pmh: asthma & parotitis. bactrim desensitization not done overnight for non histamine mediated adverse reaction (pancreatitis) per resident. pneumonia, pneumocystis jiroveci (pcp, [**name10 (nameis) **] [**name11 (nameis) **] pneumonia) assessment: rr 20-27 o2 sats 94-96% on room air. lungs: clear w/diminished breath sounds @ bases. tmax 98.9po action: given clindamycin iv q 8 hrs. response: patient is breathing comfortably. plan: transfer to floor.",1
296,"48 yr old hiv+ man transferred w/pcp pneumonia from 11r. here for bactrim desensitization. had pancreatitis in past from bactrim. pmh: asthma & parotitis. events: bactrim desensitization not done overnight for non histamine mediated adverse reaction (pancreatitis) per medical house staff. pneumonia, pneumocystis jiroveci (pcp, [**name10 (nameis) **] [**name11 (nameis) **] pneumonia) assessment: o2 sats 94-96% on room air. lung sounds diminished r rhonchi l, occasional non-productive cough action: clindamycin given response: patient is breathing comfortably. plan: transfer to floor.",1
297,"48 yr old hiv+ man transferred w/pcp pneumonia from 11r. here for bactrim desensitization. had pancreatitis in past from bactrim. pmh: asthma & parotitis. events: bactrim desensitization not done overnight for non histamine mediated adverse reaction (pancreatitis) per medical house staff. pneumonia, pneumocystis jiroveci (pcp, [**name10 (nameis) **] [**name11 (nameis) **] pneumonia) assessment: o2 sats 94-96% on room air. lung sounds diminished r rhonchi l, occasional non-productive cough action: clindamycin and primaquine given response: sats 92-94% plan: continue antibiotics for pcp [**name9 (pre) **] stable and for transfer out to medical floor, but patient refused to be transferred. he wants to leave the hospital for home. id resident assumo and icu resident [**first name8 (namepattern2) 505**] [**last name (namepattern1) **] spoke to patient about importance of staying in the hospital to continue iv clindamycin, but refused to. after several attempts of discussion regarding the need for medication patient still refused to stay in the hospital. he was discharged against medical advise with prescription for primaquine, clindamycin po and ketonazole were given by dr. [**last name (stitle) **]. ama form signed by patient. patient discharged against medical advice at around 1245 after taking his lunch. ambulatory gait steady. vital signs stable.",1
298,"72 yo female with h/o dm, htn, hld, longstanding sarcoid on home o2, newly diagnosed paroxysmal afib ([**7-4**]) s/p ddd pacemaker placement secondary to chb on [**2182-5-25**], who presented to the ed [**7-15**] with af and flash. required intubation at osh. ck elevated. transferred to [**hospital1 3476**] for cath [**7-16**]. bms to mlad . in/out of afib during cath. right fem. sheaths d/c d (minx closure) post cath. transferred on heparin and integrillin. inr elevated on transfer-> heparin d/c post cath ccu- afib/rvr 130 s. cdv x1 without success. returned to afib. rec d amio bolus 150mg x1. propofol changed to fent/versed d/t hypotension. myocardial infarction, acute (ami, stemi, nstemi) assessment: ck neg. s/p cath bms to mlad. k+ 3.7 integrillin 2mcq/k/min asa allergy right fem. cath site with minx closure- some oozing. tee done action: asa desensitization started at 1430 kcl repleted. integrellin d/c when 81 mg asa given response: no adverse reaction to asa, f/u labs pnd plan: 162 mg asa to be given at 1830, 325 mg asa to be given 3 hr later at 2130 atrial fibrillation (afib) assessment: pt remains in sinus rhythm rate 80-110, no vea. action: diltiazem gtt d/c at 0830, continues on diltiazem po 60 mg qid response: remains in sinus rhythm plan: monitor rhythm, bp. respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: initially on ac40%/450/18/40% action: vent changed to pressure support, initially [**5-5**], then [**4-30**].l suctioned for mod, lg amts thick, tan secretions. response: abg 7.36/56/63 on [**4-30**].36/56/63 on [**9-30**] w/ 50% fio2 plan: placed back on ac, 50%/ 450/18/8 peep fever, unknown origin (fuo, hyperthermia, pyrexia) assessment: tm 100.0, gpc 1 bottle from tlc line from [**7-16**] action: pan cultured (bc x2sets, sputum sent. continues on abx, cefapine got id approval response: low grade temp plan: follow cultures, temp. antibiotics. resite line neuro: pt. awake, trying to sit up and restless in the bed. straining against wrist restraints. fent/versed for sedation. fent. titrated up to of 100 mcq/hr- . versed titrated up to 3mg/hr. requiring occas. boluses to maintain comfort. not following commands. gi: nutren pulmonary started at 10cc/hr, goal 52cc/hr skin: multiple ecchymotic areas on arms, legs, chest. coccyx very red barely blanching. aloe vesta applied and pt turned side to side q 2 hr. difficulty keeping pt on side as she wiggles all over the bed.",0
299,"72 yo female with h/o dm, htn, hld, longstanding sarcoid on home o2, newly diagnosed paroxysmal afib ([**7-4**]) s/p ddd pacemaker placement secondary to chb on [**2182-5-25**], who presented to the ed [**7-15**] with af and flash. required intubation at osh. ck elevated. transferred to [**hospital1 3476**] for cath [**7-16**]. bms to mlad . in/out of afib during cath. right fem. sheaths d/c d (minx closure) post cath. transferred on heparin and integrillin. inr elevated on transfer-> heparin d/c post cath ccu- afib/rvr 130 s. cdv x1 without success. returned to afib. rec d amio bolus 150mg x1. propofol changed to fent/versed d/t hypotension. myocardial infarction, acute (ami, stemi, nstemi) assessment: ck neg. s/p cath bms to mlad. k+ 3.7 integrillin 2mcq/k/min asa allergy right fem. cath site with minx closure- some oozing. tee done action: asa desensitization started at 1430 kcl repleted. integrellin d/c when 81 mg asa given response: no adverse reaction to asa, f/u labs pnd plan: 162 mg asa to be given at 1830, 325 mg asa to be given 3 hr later at 2130 atrial fibrillation (afib) assessment: pt remains in sinus rhythm rate 80-110, no vea. action: diltiazem gtt d/c at 0830, continues on diltiazem po 60 mg qid response: remains in sinus rhythm plan: monitor rhythm, bp. respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: initially on ac40%/450/18/40% action: vent changed to pressure support, initially [**5-5**], then [**4-30**].l suctioned for mod, lg amts thick, tan secretions. response: abg 7.36/56/63 on [**4-30**].36/56/63 on [**9-30**] w/ 50% fio2 plan: placed back on ac, 50%/ 450/18/8 peep fever, unknown origin (fuo, hyperthermia, pyrexia) assessment: tm 100.0, gpc 1 bottle from tlc line from [**7-16**] action: pan cultured (bc x2sets, sputum sent. continues on abx, cefapine got id approval response: low grade temp plan: follow cultures, temp. antibiotics. resite line neuro: pt. awake, trying to sit up and restless in the bed. straining against wrist restraints. fent/versed for sedation. fent. titrated up to of 100 mcq/hr- . versed titrated up to 3mg/hr. requiring occas. boluses to maintain comfort. not following commands. gi: nutren pulmonary started at 10cc/hr, goal 52cc/hr skin: multiple ecchymotic areas on arms, legs, chest. coccyx very red barely blanching. aloe vesta applied and pt turned side to side q 2 hr. difficulty keeping pt on side as she wiggles all over the bed. ------ protected section ------ at 1745 pt went back into a fib w/ rate 140-150. sbp down to mid 80 but maintain maps>60. given 5 mg iv diltiazem x2 and started on dilt gtt at 15 mg/hr. rate remains >125. ekg done. ------ protected section addendum entered by:[**name (ni) **] [**last name (namepattern1) 2749**], rn on:[**2182-7-17**] 18:35 ------",0
300,"72 yo female with h/o dm, htn, hld, longstanding sarcoid on home o2, newly diagnosed paroxysmal afib ([**7-4**]) s/p ddd pacemaker placement secondary to chb on [**2182-5-25**], who presented to the ed [**7-15**] with af and flash. required intubation at osh. ck elevated. transferred to [**hospital1 3476**] for cath [**7-16**]. bms to mlad . in/out of afib during cath. right fem. sheaths d/c d (minx closure) post cath. transferred on heparin and integrillin. inr elevated on transfer-> heparin d/c post cath ccu- afib/rvr 130 s. cdv x1 without success. returned to afib. rec d amio bolus 150mg x1. propofol changed to fent/versed d/t hypotension. myocardial infarction, acute (ami, stemi, nstemi) assessment: ck neg. s/p cath bms to mlad. k+ 3.7 integrillin 2mcq/k/min asa allergy right fem. cath site with minx closure- some oozing. tee done action: asa desensitization started at 1430 kcl repleted. integrellin d/c when 81 mg asa given response: no adverse reaction to asa, f/u labs pnd plan: 162 mg asa to be given at 1830, 325 mg asa to be given 3 hr later at 2130 atrial fibrillation (afib) assessment: pt remains in sinus rhythm rate 80-110, no vea. action: diltiazem gtt d/c at 0830, continues on diltiazem po 60 mg qid response: remains in sinus rhythm plan: monitor rhythm, bp. respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: initially on ac40%/450/18/40% action: vent changed to pressure support, initially [**5-5**], then [**4-30**].l suctioned for mod, lg amts thick, tan secretions. response: abg 7.36/56/63 on [**4-30**].36/56/63 on [**9-30**] w/ 50% fio2 plan: placed back on ac, 50%/ 450/18/8 peep fever, unknown origin (fuo, hyperthermia, pyrexia) assessment: tm 100.0, action: pan cultured (bc x2sets, urine, sputum sent). started ab- dose of vanco, cefipime and flagyl given response: temp down to 98.6ax by 0200. skin warm/dry. plan: follow cultures, temp. antibiotics. neuro: pt. awake, trying to sit up and restless in the bed. straining against wrist restraints. fent/versed for sedation. fent. titrated up to high of 75mcq/hr- currently at 65mcq. versed titrated up to 3mg/hr. requiring occas. boluses to maintain comfort. when awake, pt. nods approp. and follows commands to squeeze hands etc. moves all extrem. gi: npo except meds. ngt clamped.",0
301,"atrial fibrillation (afib) assessment: heart rate 104-150 atrial fibrillation pt negative 400 cc in last 24 hours occasional multifocal pvc action: pt lopressor iv increased from 5mg q 6 hours to 5 mg q 4 hours lasix 40 mg iv x 1 stat electrolytes sent at 0140 response: uop increasing since lasix dose heart remains atrial fibrillation with pvc s and rate of 110-140 electolytes pending plan: continue to monitor heart rate continue to monitor urine output hourly replete electrolytes as needed bacteremia assessment: afebrile antibiotics reevaluated by team currently desensitized to meropenem action: blood culture first set sent off of cvl unable to get peripheral cultures daptomycin discontinued, [**name6 (md) 3608**] initiated md [**first name (titles) 3207**] [**last name (titles) 9373**] ct as urgent for day shift on [**2165-6-25**] response: cultures pending, will need second set afebrile plan: monitor temp awaiting culture return monitor for adverse reaction to new antibiotic did not receive po/ngt meds, ngt out on days, team does not wish to reinsert due to risk of bleeding with low platelets at this time. respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: lung sounds i/e wheeze in upper lobes, diminished in lower lobes. intubated and ventilated sedation and pain control with iv drip midazolam and fentanyl gross generalized body edema, anasarca action: mdi s by rt fio2 weaned to 40 %, peep weaned to 12 suctioned for thick tan/blood tinged secretions lasix 40 mg iv x 1 stat response: saturation remains 98-100 with vent changes lung sounds improve slightly after mdi s and suctioning. plan: rt to check abg wean vent as tolerated",1
302,"atrial fibrillation (afib) assessment: heart rate 104-150 atrial fibrillation pt negative 400 cc in last 24 hours occasional multifocal pvc action: pt lopressor iv increased from 5mg q 6 hours to 5 mg q 4 hours lasix 40 mg iv x 1 stat electrolytes sent at 0140 response: uop increasing since lasix dose heart remains atrial fibrillation with pvc s and rate of 110-140 electolytes pending plan: continue to monitor heart rate continue to monitor urine output hourly replete electrolytes as needed bacteremia assessment: afebrile antibiotics reevaluated by team currently desensitized to meropenem action: blood culture first set sent off of cvl unable to get peripheral cultures daptomycin discontinued, [**name6 (md) 3608**] initiated md [**first name (titles) 3207**] [**last name (titles) 9373**] ct as urgent for day shift on [**2165-6-25**] response: cultures pending, will need second set afebrile plan: monitor temp awaiting culture return monitor for adverse reaction to new antibiotic did not receive po/ngt meds, ngt out on days, team does not wish to reinsert due to risk of bleeding with low platelets at this time. respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: lung sounds i/e wheeze in upper lobes, diminished in lower lobes. intubated and ventilated sedation and pain control with iv drip midazolam and fentanyl gross generalized body edema, anasarca action: mdi s by rt fio2 weaned to 40 %, peep weaned to 12 suctioned for thick tan/blood tinged secretions lasix 40 mg iv x 1 stat response: saturation remains 98-100 with vent changes lung sounds improve slightly after mdi s and suctioning. plan: rt to check abg wean vent as tolerated",1
303,"sicu hpi: 70yo m w/ persistent abd pain, poor po intake, w/ gallstone pancreatitis, complicated by abdominal compartment syndrome following ercp, ards, septic vasodilatory shock, cdiff, and arf. now with necrotizing pancreatitis s/p drain placement and multiple necrosectomies. chief complaint: necrotizing pancreatitis pmhx: asthma, htn, basal cell ca current medications: acetaminophen, calcium gluconate, chlorhexidine gluconate 0.12% oral rinse, hydromorphone (dilaudid, heparin, insulin, ipratropium bromide mdi, magnesium sulfate, metoprolol tartrate, midazolam, olanzapine (disintegrating tablet), ondansetron, sarna lotion 24 hour events: dialysis catheter - stop [**2113-9-26**] 10:51 am dialysis catheter - start [**2113-9-26**] 10:55 am percutaneous tracheostomy - at [**2113-9-26**] 12:33 pm trach changed from #7 portex to #8 dic portex. no adverse reactions noted. keep l flank drain in place for now per dr. [**first name (stitle) **]. tf started at 20. post operative day: pod#86 - ex lap for compartment syndrome. 2 drains to wall suction. exam otherwise unchanged from previous. pod#81 - s/p abdominal partial closure and dressing change pod#75 - abdominal wound closure; insertion of g-j tube pod#70 - ex lap pod#65 - trach and abd washout pod#60 - ex-lap and mesh closure of abdomen pod#40 - replacement of pancreatic drain for abscess including irrigation port pod#36 - laparoscopic pancreatic necrosectomy pod#23 - washout of peripancreatic space. allergies: aspirin unknown; sulfa (sulfonamide antibiotics) rash; last dose of antibiotics: infusions: other icu medications: midazolam (versed) - [**2113-9-26**] 12:30 pm heparin sodium (prophylaxis) - [**2113-9-27**] 08:00 am metoprolol - [**2113-9-27**] 08:30 am other medications: flowsheet data as of [**2113-9-27**] 09:22 am vital signs hemodynamic monitoring fluid balance 24 hours since [**16**] a.m. tmax: 37.4 c (99.4 t current: 37.3 c (99.1 hr: 105 (93 - 112) bpm bp: 124/66(85) {110/61(78) - 157/77(104)} mmhg rr: 21 (14 - 24) insp/min spo2: 100% heart rhythm: st (sinus tachycardia) wgt (current): 83 kg (admission): 108.3 kg height: 64 inch cvp: 5 (3 - 11) mmhg total in: 2,005 ml 914 ml po: tube feeding: 60 ml 165 ml iv fluid: 240 ml 92 ml blood products: total out: 2,285 ml 575 ml urine: 1,700 ml 535 ml ng: 395 ml stool: drains: 190 ml 40 ml balance: -280 ml 339 ml respiratory support o2 delivery device: tracheostomy tube ventilator mode: cpap/psv vt (spontaneous): 491 (451 - 605) ml ps : 8 cmh2o rr (spontaneous): 21 peep: 5 cmh2o fio2: 40% rsbi: 68 pip: 15 cmh2o spo2: 100% abg: 7.39/38/170/22/-1 ve: 9.6 l/min pao2 / fio2: 425 physical examination general appearance: no acute distress heent: perrl cardiovascular: (rhythm: regular) respiratory / chest: (expansion: symmetric), coarse bilaterally, no wheezes abdominal: distended left extremities: (edema: 1+), (temperature: warm) right extremities: (edema: 1+), (temperature: warm) neurologic: follows simple commands, (responds to: verbal stimuli, tactile stimuli, noxious stimuli), moves all extremities labs / radiology 299 k/ul 8.5 g/dl 156 mg/dl 3.5 mg/dl 22 meq/l 3.7 meq/l 101 mg/dl 111 meq/l 143 meq/l 26.8 % 8.6 k/ul [image002.jpg] [**2113-9-23**] 08:52 pm [**2113-9-23**] 09:03 pm [**2113-9-24**] 04:14 am [**2113-9-24**] 04:33 am [**2113-9-25**] 02:49 am [**2113-9-25**] 02:50 am [**2113-9-26**] 03:07 am [**2113-9-26**] 03:19 am [**2113-9-27**] 05:13 am [**2113-9-27**] 05:53 am wbc 11.3 11.7 11.2 9.5 8.6 hct 26.8 26.3 26.7 26.3 26.8 plt [**telephone/fax (3) 10206**]87 299 creatinine 2.7 2.9 3.3 3.6 3.5 tco2 31 30 29 26 24 glucose 111 110 114 121 156 other labs: pt / ptt / inr:19.7/117.8/1.8, ck / ck-mb / troponin t:57/5/0.38, alt / ast:14/23, alk-phos / t bili:93/0.6, amylase / lipase:87/20, differential-neuts:72.0 %, band:6.0 %, lymph:11.0 %, mono:5.0 %, eos:1.0 %, fibrinogen:738 mg/dl, lactic acid:1.9 mmol/l, albumin:1.9 g/dl, ldh:151 iu/l, ca:8.9 mg/dl, mg:1.9 mg/dl, po4:3.9 mg/dl assessment and plan ineffective coping, impaired skin integrity, renal failure, acute (acute renal failure, arf), electrolyte & fluid disorder, other, anxiety, pancreatic pseudocyst, arousal, attention, and cognition, impaired, gait, impaired, knowledge, impaired, transfers, impaired, .h/o fever (hyperthermia, pyrexia, not fever of unknown origin), pain control (acute pain, chronic pain) assessment and plan: 70m w/ gallstone pancreatitis s/p failed ercp and abdominal compartment syndrome([**2113-7-2**]) c/b vasodilatory sirs shock w/subsequent decompressive exploratory laparotomy ([**2113-7-3**]) w/ persistent open abdomen, expansion of wound ([**2113-7-3**]) bleeding dieulafoy's s/p clipping ([**2113-7-17**]) arf, s/p episode ards and c.diff, s/p abd closure and repeat decompressive ex lap ([**2113-7-19**]), now trached ([**2113-7-24**]), partial closure with mesh ([**2113-7-29**]) and wound vac ([**2113-8-1**]). repeatedly febrile, repeat abd ct shows air in pancreas. now s/p drainage of pancreatic collection by ir ([**2113-8-13**]) upsizing of drain ([**2113-8-18**]), laparoscopic minimally invasive pancreatic necrosectomy ([**2113-8-22**], [**2113-8-28**], [**2113-9-4**]) for necrotizing pancreatitis. neurologic: pain controlled, improved ms [**first name (titles) **] [**last name (titles) **] s/p acidosis vs infection. dilaudid, tylenol prn. zyprexa sl prn agitation/anxiety. cardiovascular: no issues. lopressor 5 iv q4h. l femoral line rewired for access [**9-26**]. pulmonary: cont ett, spontaneous breathing trial, (ventilator mode: cpap + ps), prior failure to wean extended vent course d/t atelectasis, agitation, acid/base, and now trach, deconditioning. trach revision [**9-26**]. cpap/ps. trach collar as tol. low albumin, tires quickly. maximize nutrition. trach mask trial gastrointestinal / abdomen: pancreaticocolonic fistula. pancreatic necrosis irrigation stopped. [**month (only) 51**] resume tf despite colonic fistula w/ good output. keep tf at 20 cc/hr. renal: atn w/acidosis and volume overload. hd [**2113-9-18**], last cycle [**9-23**]. l femoral hd s/p tpa x3 w/o results- d/c. attempt to rewire l femoral catheter. requests r femoral for hd. r subclavian as last alternative (high stenosis risk). nutrition: tpn, tube feeding, tf started at 20, no feculent drainage. daily tpn - aa increased [**9-23**] for low albumin of 2.0. check pre-albumin, albumin, transferrin results renal: foley, adequate uo, atn w/acidosis and volume overload. hd [**2113-9-18**], last cycle today. l femoral hd s/p tpa x3 w/o results- d/c. attempt to rewire l femoral catheter. requests r femoral for hd. r subclavian as last alternative (high stenosis risk). hematology: pt requires ~8hrs notice for any blood products [**2-6**] unusual abs. persistent lij clots (heparin gtt x wks). last product 2u prbcs w/ hd [**9-23**]. endocrine: riss, endocrine pancreas functioning 30u regular in tpn. minimal riss. infectious disease: check cultures, no abx at this point. monitor wbc lines / tubes / drains: foley, g-tube, j-tube, trach, surgical drains (hemovac, jp), l hd femoral cath, l subclavian cvl wounds: wet / dry dressings, wound vacuum, abdomen wound vac (changed [**9-21**]). left flank wound around panc tube. wet>dry [**hospital1 7**] per [**doctor first name 213**] att/res. imaging: fluids: kvo consults: nephrology billing diagnosis: pancreatitis resp failure. icu care nutrition: tpn w/ lipids - [**2113-9-26**] 03:28 pm 71 ml/hour novasource renal (full) - [**2113-9-26**] 06:00 pm 20 ml/hour glycemic control: regular insulin sliding scale lines: multi lumen - [**2113-9-12**] 03:43 pm arterial line - [**2113-9-12**] 08:45 pm picc line - [**2113-9-24**] 05:05 pm dialysis catheter - [**2113-9-26**] 10:55 am prophylaxis: dvt: boots, sq uf heparin stress ulcer: h2 blocker, ppi, sucralafate, not indicated vap bundle: hob elevation, mouth care, rsbi comments: communication: patient discussed on interdisciplinary rounds comments: code status: full code disposition: icu total time spent: 31 min",0
304,"aerobic capacity / endurance, impaired assessment: noted doe, easily fatigues deconditoned action: pt today , pt ambulated w/ 2 pt and belt holding w/c response: tolerated pt session no adverse reaction plan: cont active and passive rom , oob to chair ambulate w/ pt may need rehab airway clearance, impaired assessment: audible rhonchi, poor oral muscle coordination action: oob to chair for 6 hours today, aggressive pulm toileting, cont on 35% face shovel for moisture , attempted is use response: unable to use is , sats mid 90 s , able to suction s/p resp osscilator treatment plan: cont aggressive pulm toileting, resp oscillator treatments as ordered, cont face shovel for moisture",0
305,"sicu hpi: 70yo m w/ persistent abd pain, poor po intake, w/ gallstone pancreatitis, complicated by abdominal compartment syndrome following ercp, ards, septic vasodilatory shock, cdiff, and arf. now with necrotizing pancreatitis s/p drain placement and multiple necrosectomies. chief complaint: necrotizing pancreatitis pmhx: asthma, htn, basal cell ca current medications: acetaminophen, calcium gluconate, chlorhexidine gluconate 0.12% oral rinse, hydromorphone (dilaudid, heparin, insulin, ipratropium bromide mdi, magnesium sulfate, metoprolol tartrate, midazolam, olanzapine (disintegrating tablet), ondansetron, sarna lotion 24 hour events: dialysis catheter - stop [**2113-9-26**] 10:51 am dialysis catheter - start [**2113-9-26**] 10:55 am percutaneous tracheostomy - at [**2113-9-26**] 12:33 pm trach changed from #7 portex to #8 dic portex. no adverse reactions noted. keep l flank drain in place for now per dr. [**first name (stitle) **]. tf started at 20. post operative day: pod#86 - ex lap for compartment syndrome. 2 drains to wall suction. exam otherwise unchanged from previous. pod#81 - s/p abdominal partial closure and dressing change pod#75 - abdominal wound closure; insertion of g-j tube pod#70 - ex lap pod#65 - trach and abd washout pod#60 - ex-lap and mesh closure of abdomen pod#40 - replacement of pancreatic drain for abscess including irrigation port pod#36 - laparoscopic pancreatic necrosectomy pod#23 - washout of peripancreatic space. allergies: aspirin unknown; sulfa (sulfonamide antibiotics) rash; last dose of antibiotics: infusions: other icu medications: midazolam (versed) - [**2113-9-26**] 12:30 pm heparin sodium (prophylaxis) - [**2113-9-27**] 08:00 am metoprolol - [**2113-9-27**] 08:30 am other medications: flowsheet data as of [**2113-9-27**] 09:22 am vital signs hemodynamic monitoring fluid balance 24 hours since [**16**] a.m. tmax: 37.4 c (99.4 t current: 37.3 c (99.1 hr: 105 (93 - 112) bpm bp: 124/66(85) {110/61(78) - 157/77(104)} mmhg rr: 21 (14 - 24) insp/min spo2: 100% heart rhythm: st (sinus tachycardia) wgt (current): 83 kg (admission): 108.3 kg height: 64 inch cvp: 5 (3 - 11) mmhg total in: 2,005 ml 914 ml po: tube feeding: 60 ml 165 ml iv fluid: 240 ml 92 ml blood products: total out: 2,285 ml 575 ml urine: 1,700 ml 535 ml ng: 395 ml stool: drains: 190 ml 40 ml balance: -280 ml 339 ml respiratory support o2 delivery device: tracheostomy tube ventilator mode: cpap/psv vt (spontaneous): 491 (451 - 605) ml ps : 8 cmh2o rr (spontaneous): 21 peep: 5 cmh2o fio2: 40% rsbi: 68 pip: 15 cmh2o spo2: 100% abg: 7.39/38/170/22/-1 ve: 9.6 l/min pao2 / fio2: 425 physical examination general appearance: no acute distress heent: perrl cardiovascular: (rhythm: regular) respiratory / chest: (expansion: symmetric), coarse bilaterally, no wheezes abdominal: distended left extremities: (edema: 1+), (temperature: warm) right extremities: (edema: 1+), (temperature: warm) neurologic: follows simple commands, (responds to: verbal stimuli, tactile stimuli, noxious stimuli), moves all extremities labs / radiology 299 k/ul 8.5 g/dl 156 mg/dl 3.5 mg/dl 22 meq/l 3.7 meq/l 101 mg/dl 111 meq/l 143 meq/l 26.8 % 8.6 k/ul [image002.jpg] [**2113-9-23**] 08:52 pm [**2113-9-23**] 09:03 pm [**2113-9-24**] 04:14 am [**2113-9-24**] 04:33 am [**2113-9-25**] 02:49 am [**2113-9-25**] 02:50 am [**2113-9-26**] 03:07 am [**2113-9-26**] 03:19 am [**2113-9-27**] 05:13 am [**2113-9-27**] 05:53 am wbc 11.3 11.7 11.2 9.5 8.6 hct 26.8 26.3 26.7 26.3 26.8 plt [**telephone/fax (3) 10206**]87 299 creatinine 2.7 2.9 3.3 3.6 3.5 tco2 31 30 29 26 24 glucose 111 110 114 121 156 other labs: pt / ptt / inr:19.7/117.8/1.8, ck / ck-mb / troponin t:57/5/0.38, alt / ast:14/23, alk-phos / t bili:93/0.6, amylase / lipase:87/20, differential-neuts:72.0 %, band:6.0 %, lymph:11.0 %, mono:5.0 %, eos:1.0 %, fibrinogen:738 mg/dl, lactic acid:1.9 mmol/l, albumin:1.9 g/dl, ldh:151 iu/l, ca:8.9 mg/dl, mg:1.9 mg/dl, po4:3.9 mg/dl assessment and plan ineffective coping, impaired skin integrity, renal failure, acute (acute renal failure, arf), electrolyte & fluid disorder, other, anxiety, pancreatic pseudocyst, arousal, attention, and cognition, impaired, gait, impaired, knowledge, impaired, transfers, impaired, .h/o fever (hyperthermia, pyrexia, not fever of unknown origin), pain control (acute pain, chronic pain) assessment and plan: 70m w/ gallstone pancreatitis s/p failed ercp and abdominal compartment syndrome([**2113-7-2**]) c/b vasodilatory sirs shock w/subsequent decompressive exploratory laparotomy ([**2113-7-3**]) w/ persistent open abdomen, expansion of wound ([**2113-7-3**]) bleeding dieulafoy's s/p clipping ([**2113-7-17**]) arf, s/p episode ards and c.diff, s/p abd closure and repeat decompressive ex lap ([**2113-7-19**]), now trached ([**2113-7-24**]), partial closure with mesh ([**2113-7-29**]) and wound vac ([**2113-8-1**]). repeatedly febrile, repeat abd ct shows air in pancreas. now s/p drainage of pancreatic collection by ir ([**2113-8-13**]) upsizing of drain ([**2113-8-18**]), laparoscopic minimally invasive pancreatic necrosectomy ([**2113-8-22**], [**2113-8-28**], [**2113-9-4**]) for necrotizing pancreatitis. neurologic: pain controlled, improved ms [**first name (titles) **] [**last name (titles) **] s/p acidosis vs infection. dilaudid, tylenol prn. zyprexa sl prn agitation/anxiety. cardiovascular: no issues. lopressor 5 iv q4h. l femoral line rewired for access [**9-26**]. pulmonary: cont ett, spontaneous breathing trial, (ventilator mode: cpap + ps), prior failure to wean extended vent course d/t atelectasis, agitation, acid/base, and now trach, deconditioning. trach revision [**9-26**]. cpap/ps. trach collar as tol. low albumin, tires quickly. maximize nutrition. gastrointestinal / abdomen: pancreaticocolonic fistula. pancreatic necrosis irrigation stopped. [**month (only) 51**] resume tf despite colonic fistula w/ good output. renal: atn w/acidosis and volume overload. hd [**2113-9-18**], last cycle [**9-23**]. l femoral hd s/p tpa x3 w/o results- d/c. attempt to rewire l femoral catheter. requests r femoral for hd. r subclavian as last alternative (high stenosis risk). nutrition: tpn, tube feeding, tf started at 20, no feculent drainage. daily tpn - aa increased [**9-23**] for low albumin of 2.0. check pre-albumin, albumin, transferrin results renal: foley, adequate uo, atn w/acidosis and volume overload. hd [**2113-9-18**], last cycle today. l femoral hd s/p tpa x3 w/o results- d/c. attempt to rewire l femoral catheter. requests r femoral for hd. r subclavian as last alternative (high stenosis risk). hematology: pt requires ~8hrs notice for any blood products [**2-6**] unusual abs. persistent lij clots (heparin gtt x wks). last product 2u prbcs w/ hd [**9-23**]. endocrine: riss, endocrine pancreas functioning 30u regular in tpn. minimal riss. infectious disease: check cultures, no abx at this point. monitor wbc lines / tubes / drains: foley, g-tube, j-tube, trach, surgical drains (hemovac, jp), l hd femoral cath, l subclavian cvl wounds: wet / dry dressings, wound vacuum, abdomen wound vac (changed [**9-21**]). left flank wound around panc tube. wet>dry [**hospital1 7**] per [**doctor first name 213**] att/res. imaging: fluids: kvo consults: nephrology billing diagnosis: pancreatitis icu care nutrition: tpn w/ lipids - [**2113-9-26**] 03:28 pm 71 ml/hour novasource renal (full) - [**2113-9-26**] 06:00 pm 20 ml/hour glycemic control: regular insulin sliding scale lines: multi lumen - [**2113-9-12**] 03:43 pm arterial line - [**2113-9-12**] 08:45 pm picc line - [**2113-9-24**] 05:05 pm dialysis catheter - [**2113-9-26**] 10:55 am prophylaxis: dvt: boots, sq uf heparin stress ulcer: h2 blocker, ppi, sucralafate, not indicated vap bundle: hob elevation, mouth care, rsbi comments: communication: patient discussed on interdisciplinary rounds comments: code status: full code disposition: icu total time spent:",0
306,"65m admitted [**10-18**] for r le bka, with course c/b afib with rvr s/p dccvx1, hypotension, and hypercarbic respiratory failure, on [**10-27**] prompting intubation and transient pressor support. respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: received pt intubated on cpap+ps 30% 8/5, lung sounds coarse to diminished, suctioned for small amounts of tan secretions via ett. pt off all sedation, sleeping intermittently, following commands consistently, attempting to help with turns, denies pain. respiratory failure likely related to autoimmune necrotizing myopathy. action: passed am rsbi, sbt done this am with slight decrease in pao2. per prior medical notes and micu rounds ivig given during pt s last intubation with positive effect. pt s neurologist was called and information was confirmed. ivig ordered and to be given for next 5 days. given pt s history of sensitivity pt premedicated with acetaminophen and pepcid. per rounds pt also showing fluid overload on cxr. given 40mg lasix x 2 for fluid goal of -1l at mn. on cellcept and prednisone. response: pt tolerating ivig transfusion well, no signs/symptoms of adverse reaction. pt with moderate response to iv lasix, at this writing pt is -770cc. plan: continue ivig treatment for next 4 days, monitor for signs/symptoms of adverse reaction, premedicate as ordered. pulmonary toilet. lasix as needed for fluid removal. infection assessment: pt s most recent wound culture growing pseudomonas ([**10-28**]). pt afebrile. action: on cefepime and vanc for treatment of pseudomonas. vanco level checked and ordered for prn dose for level <15. response: vanco level 24, no prn dose given. plan: continue iv abx, vanc trough in am. impaired skin integrity assessment: pt with skin breakdown under pannus and peri-anally. pt having large amounts of liquid stool this am. incision to r bka draining small amounts of pus from left lateral end. action: wound care in to evaluate breakdown, recommended criticaid clear to all areas. flexiseal placed for diarrhea and to prevent further breakdown. dressing to r bka changed. response: criticaid applied, no new skin breakdown noted. small amount of blood noted post insertion of flexiseal from anus. ho aware. plan: meticulous skin care, frequent turns, flexiseal for diarrhea, criticaid clear to areas of breakdown. am na 146 started on free water 100 q6h. pm lytes pending",0
307,"65m admitted [**10-18**] for r le bka, with course c/b afib with rvr s/p dccvx1, hypotension, and hypercarbic respiratory failure, on [**10-27**] prompting intubation and transient pressor support. respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: received pt intubated on cpap+ps 30% 8/5, lung sounds coarse to diminished, suctioned for small amounts of tan secretions via ett. pt off all sedation, sleeping intermittently, following commands consistently, attempting to help with turns, denies pain. action: passed am rsbi, sbt done this am with slight decrease in pao2. per prior medical notes and micu rounds ivig given during pt s last intubation with positive effect. pt s neurologist was called and information was confirmed. ivig ordered and to be given for next 5 days. given pt s history of sensitivity pt premedicated with acetaminophen and pepcid. per rounds pt also showing fluid overload on cxr. given 40mg lasix x 2 for fluid goal of -1l at mn. response: pt tolerating ivig transfusion well, no signs/symptoms of adverse reaction. pt with moderate response to iv lasix, at this writing pt is -770cc. plan: continue ivig treatment for next 4 days, monitor for signs/symptoms of adverse reaction, premedicate as ordered. pulmonary toilet. lasix as needed for fluid removal. infection assessment: pt s most recent wound culture growing pseudomonas ([**10-28**]). pt afebrile. action: on cefepime and vanc for treatment of pseudomonas. vanco level checked and ordered for prn dose for level <15. response: vanco level 24, no prn dose given. plan: continue iv abx, vanc trough in am. impaired skin integrity assessment: pt with skin breakdown under pannus and peri-anally. pt having large amounts of liquid stool this am. incision to r bka draining small amounts of pus from left lateral end. action: wound care in to evaluate breakdown, recommended criticaid clear to all areas. flexiseal placed for diarrhea and to prevent further breakdown. dressing to r bka changed. response: criticaid applied plan: am na 146 started on free water 100 q6h. pm lytes pending",0
308,"65m admitted [**10-18**] for r le bka, with course c/b afib with rvr s/p dccvx1, hypotension, and hypercarbic respiratory failure, on [**10-27**] prompting intubation and transient pressor support. respiratory failure, acute (not ards/[**doctor last name 11**]) assessment: received pt on cpap+ps 30%/[**6-21**], stv 300s, mv [**12-23**], rr teens, lung sounds clear, respirations even and unlabored. a-line with good waveform however unable to draw off of. action: passed am rsbi, put on sbt trial this am 30%/5/0. suctioned x 1 for small, tan, thick secretions. cxr noted to be somewhat improved. vbgs used to assess respiratory status instead of a-line, used for monitoring only. ivig given as ordered, on day 2 of 5, premedicated with tylenol and pepcid prior to transfusion given history of sensitivity. response: slight difference between pre and post sbt vbgs however given waxing and [**doctor last name 533**] mental status and pt s lethargy decision made to postpone extubation. ivig infusing without incident, no signs/symptoms of adverse reaction noted. plan: continue course of ivig treatment. continue to assess mental status and ability to extubated. altered mental status (not delirium) assessment: pt s mental status waxing and [**doctor last name 533**] throughout shift. at times opens eyes to voice and able to follow commands other times opens eyes to voice but unable to keep open long enough to speak to. action: given pt s lethargic condition extubation postponed until able to consistently follow commands. response: no change in mental status. plan: continue to assess mental status frequently and readiness to extubated.",0
309,"pt is a 42 y.o male with no pmh who was originally transferred from [**hospital **] hospital for eval and tx of a new mediastinal mass and pe. pt reports was in usoh until ~4wks ago when he developed a fever, non-productive cough, scratchy throat and severe sob (+orthopnea and doe), facial+neck swelling, cyanotic ears/lips, decreased appetite (wt loss 10-12lbs). he also reports sharp r.sided lateral chest/rib pain, with occasional radiation down his r.arm and a dull discomfort in his ruq. he also reports a white spot in his r.eye vision, that has since resolved. he reported 2 episodes of n/v over this 4 wk period. he denies travel, sick contacts, headache, blurred vision, odynophagia, dysphagia, palps/d/c/melena/brpbr/dysuria/paresthesias /weakness/skin rash. he then presented to [**location (un) 12946**] urgent care [**2171-2-14**] where a large lung mass was found on cxr. he was then admitted to [**hospital **] hospital. there, ct chest showed a large [**location (un) 6705**] invading the r.mediastinum causing severe compression, but no occlusion of the svc. this mass was in contact with the pulmonary artery. labs showed afp 1303, ldh 407, normal b-hcg. ct guided bx showed malignant cells c/w poorly differentiated carcinoma (ddx carcinomatosis of immature teratoma within mixed cell germ tumor or poorly differentiated carcinoma with non-small cell morphology. therefore, pt was transferred to [**hospital1 19**] for mediastinoscopy and further care. pt now being transferred to the [**hospital ward name 1437**] for the initiation of chemotherapy. pt will require icu given possibility of tumor swelling causing complete svc occlusion (ir vs. vasc would need to stent). onc felt comfortable starting [**hospital ward name 2007**] if no liver lesions. currently ?defect in falciform ligament, radiology rec u/s. pt with pan scan at osh. **pt to have mri of liver today as a hypodensity was seen on ultrasound. cancer (malignant neoplasm), lung assessment: pt with large tumor of right lung partially occluding svc. received pt on 3l nc with o2 sats 94-97%, right sided lung sounds diminished with minimal audible breath sounds, left upper lungs clear/diminished at bases. action: pt seen by onc md who recommended [**hospital ward name 2007**] to start tonite. pt ordered for etoposide 195mg iv x5 days and cisplatin 40mg iv x5 days. [**name6 (md) **] certified rn up to administer at 0030. pt premedicated with allopurinol, decadron, and zofran. also prehydrated with 500cc ns. response: [**name6 (md) **] administered without any reactions, pt tolerated well without adverse reactions. post hydrated with 500cc ns. no c/o n/v. plan: pt to cont for 4 more doses of etoposide and cisplatin. then will need 4 more cycles. prior to administration of [**name6 (md) 2007**], pt needs to receive zofran and decadron. also needs to receive allopurinol daily. plan is to have picc placed today. pt had am chest xray, f/u.",0
310,"pt is a 42 y.o male with no pmh who was originally transferred from [**hospital **] hospital for eval and tx of a new mediastinal mass and pe. pt reports was in usoh until ~4wks ago when he developed a fever, non-productive cough, scratchy throat and severe sob (+orthopnea and doe), facial+neck swelling, cyanotic ears/lips, decreased appetite (wt loss 10-12lbs). he also reports sharp r.sided lateral chest/rib pain, with occasional radiation down his r.arm and a dull discomfort in his ruq. he also reports a white spot in his r.eye vision, that has since resolved. he reported 2 episodes of n/v over this 4 wk period. he denies travel, sick contacts, headache, blurred vision, odynophagia, dysphagia, palps/d/c/melena/brpbr/dysuria/paresthesias /weakness/skin rash. he then presented to [**location (un) 12946**] urgent care [**2171-2-14**] where a large lung mass was found on cxr. he was then admitted to [**hospital **] hospital. there, ct chest showed a large [**location (un) 6705**] invading the r.mediastinum causing severe compression, but no occlusion of the svc. this mass was in contact with the pulmonary artery. labs showed afp 1303, ldh 407, normal b-hcg. ct guided bx showed malignant cells c/w poorly differentiated carcinoma (ddx carcinomatosis of immature teratoma within mixed cell germ tumor or poorly differentiated carcinoma with non-small cell morphology. therefore, pt was transferred to [**hospital1 19**] for mediastinoscopy and further care. pt now being transferred to the [**hospital ward name 1437**] for the initiation of chemotherapy. pt will require icu given possibility of tumor swelling causing complete svc occlusion (ir vs. vasc would need to stent). onc felt comfortable starting [**hospital ward name 2007**] if no liver lesions. currently ?defect in falciform ligament, radiology rec u/s. pt with pan scan at osh. **pt to have mri of liver today as a hypodensity was seen on ultrasound. cancer (malignant neoplasm), lung assessment: pt with large tumor of right lung partially occluding svc. received pt on 3l nc with o2 sats 94-97%, right sided lung sounds diminished with minimal audible breath sounds, left upper lungs clear/diminished at bases. action: pt seen by onc md who recommended [**hospital ward name 2007**] to start tonite. pt ordered for etoposide 195mg iv x5 days and cisplatin 40mg iv x5 days. [**name6 (md) **] certified rn up to administer at 0030. pt premedicated with allopurinol, decadron, and zofran. also prehydrated with 500cc ns. response: [**name6 (md) **] administered without any reactions, pt tolerated well without adverse reactions. post hydrated with 500cc ns. no c/o n/v. plan: pt to cont for 4 more doses of etoposide and cisplatin. then will need 4 more cycles. prior to administration of [**name6 (md) 2007**], pt needs to receive zofran and decadron. also needs to receive allopurinol daily. plan is to have picc placed today. pt had am chest xray, f/u.",0
311,"chief complaint: hypotension and fever hpi: hpi: 63 year old male with ms (bedbound), chronic utis, htn s/p total knee replacement who was grought to [**hospital1 1200**] by his vna on [**1-23**] for concern for septic arthritis (cellulitis overlying the arthocentesis with swollen, red knee). at the osh he had a cbc with wbc 16.8, hgb 10.7, cxr normal, x-ray of the knee not consistent with osteomyelitis, but limited study, u/a was positive and he received 1g of ertapenem with no adverse reaction. per osh notes, the patient has not had vre or mrsa in previous cultures. he was then transferred to [**hospital1 19**] for washout. he was taken to the or on [**1-24**] for i&d r knee and vac placement (krod). the or notes that there was purulent subq collection at ant-medial proximal tibia (swabs sent). fibrinous-purulent synovium throughout (tissue sent for micro/path). bone biopsy sent from anterior tibia (not grossly infected). patellar component (plastic) was grossly loose from patella and removed. femur and tibial hardware appear seated. likely periosteal rxn at anterior femur suggests chronic infxn, but pt states wound has been present 3-4wks. . post operatively, synovial tissue with 2+ gpcs, the patient was started on vancomycin though it is unclear if he ever received his doses. he initially did well, then was noted to have fever 102.4 and bp 72/40 at midnight. he was given a 500cc bolus and a hct was sent. his bp did not improve after three 500cc boluses over 4 hours. his hct was 25 from 29 and he was ordered for 2 units prbcs. his ekg was nsr. of note, he received atenolol and spironolactone (his home bp meds). he was on a morphine pca without a basal rate and only had 1.5mg over the evening. . on arrival to the icu the patient is alert, oriented, denies dizziness, sob, chest pain and he has good urine output. his bp increased to 93/60 after 3l ivf and 1 unit prbcs. per the am ortho resident, the patient is unlikely to be a candidate for revision and if he does not improve he may need a bka. allergies: penicillins unknown; last dose of antibiotics: aztreonam - [**2104-1-25**] 08:00 am vancomycin - [**2104-1-25**] 08:21 am infusions: other icu medications: other medications: past medical history: family history: social history: hypertension ""sepsis""??? hemiplegia neurogenic bladder multiple sclerosis (bilat le paralysis since [**2088**], lue paralysis) stage 3 ulcer on lateral aspect of his right r tka (likely a revision from [**2083**], pt reports previous operations on the r knee prior to tkr). recurrent utis (no known problems with resistant organisms, last uti treated last year per ortho note). hypertension occupation: drugs: denies tobacco: alcohol: denies other: lives at home alone with vna/personal caregiver review of systems: constitutional: fever eyes: no(t) blurry vision ear, nose, throat: dry mouth cardiovascular: no(t) chest pain, no(t) tachycardia, no(t) orthopnea respiratory: no(t) cough, no(t) dyspnea gastrointestinal: no(t) abdominal pain, no(t) nausea, no(t) diarrhea genitourinary: no(t) dysuria, foley neurologic: no(t) numbness / tingling, no(t) headache, no(t) seizure psychiatric / sleep: no(t) agitated flowsheet data as of [**2104-1-25**] 11:54 am vital signs hemodynamic monitoring fluid balance 24 hours since [**05**] am tmax: 37.6 c (99.7 tcurrent: 36.6 c (97.8 hr: 79 (74 - 87) bpm bp: 113/56(69) {77/42(51) - 113/56(69)} mmhg rr: 17 (12 - 18) insp/min spo2: 98% heart rhythm: sr (sinus rhythm) height: 68 inch total in: 6,555 ml po: tf: ivf: 1,330 ml blood products: 375 ml total out: 0 ml 1,260 ml urine: 1,260 ml ng: stool: drains: balance: 0 ml 5,295 ml respiratory o2 delivery device: none spo2: 98% abg: ///25/ physical examination general appearance: no acute distress eyes / conjunctiva: perrl, conjunctiva pale head, ears, nose, throat: normocephalic cardiovascular: no murmur peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: diminished), (left dp pulse: diminished) respiratory / chest: (expansion: symmetric), (breath sounds: clear : ) abdominal: soft, non-tender, pressure ulcer with granulation tissue at base on central abdomen extremities: r leg wrapped with drain serosang musculoskeletal: unable to stand skin: not assessed, no(t) rash: neurologic: attentive, follows simple commands, responds to: verbal stimuli, oriented (to): person place and time, movement: not assessed, tone: not assessed labs / radiology 475 k/ul 7.2 g/dl 127 mg/dl 0.3 mg/dl 4 mg/dl 25 meq/l 108 meq/l 4.0 meq/l 138 meq/l 23.9 % 11.3 k/ul [image002.jpg] [**2099-12-7**] 2:33 a2/19/[**2103**] 05:46 am [**2099-12-11**] 10:20 p [**2099-12-12**] 1:20 p [**2099-12-13**] 11:50 p [**2099-12-14**] 1:20 a [**2099-12-15**] 7:20 p 1//11/006 1:23 p [**2100-1-7**] 1:20 p [**2100-1-7**] 11:20 p [**2100-1-7**] 4:20 p wbc 11.3 hct 23.9 plt 475 cr 0.3 glucose 127 other labs: pt / ptt / inr:16.1/29.5/1.4, differential-neuts:79.4 %, lymph:13.7 %, mono:5.1 %, eos:1.5 %, lactic acid:0.6 mmol/l, albumin:1.9 g/dl, ca++:6.3 mg/dl, mg++:1.6 mg/dl, po4:3.0 mg/dl assessment and plan assessment and plan: 63 year old male with hypertension, admitted for presumed septic knee, s/p washout with onset of fever and hypotension moderately responsive to fluids. . #shock: fever, hypotension, wbc count with infected knee (gpcs on gram stain) likely due to infection (knee most likely, but patient also with chronic utis and + u/a at osh so gu source also possible). however, patient with blood loss from wound vac and in or, so volume repletion likely contributing. also, patient restarted long acting bb yesterday after the or, w/ nodal blockade so unable to mount a hr response to increase cardiac output. -blood cultures -urine cultures -check lactate -call [**hospital3 **] to find out micro about his u/a -vanco for gpcs, f/u cultures -aztreonam and cipro for gnrs given pcn allergy -ivf for goal map 55, monitor urine -transfuse 2 units prbcs and recheck hct -echo to eval for cardiogenic compotent -hold home bp meds -guaiac stool -repeat ekg -f/u ortho recs -wound care consult . #septic arthritis: patient with old hardware in place, and per ortho unlikely to get a revision. will need to consider speaking to patient about possibility of amputation in the future. -id consult for antibiotic regimen/duration recommendation -continue wound vac -vanco for gpcs in synovium -f/u wound/fluid/tissue cultures -f/u ortho recs -id consult for abx course for ?infected hardware in knee . # positive u/a: had + u/a at osh, received 1 dose of ertapenem?, negative u/a here. unclear if represents colonization or infection in patient with chronic foley, however, will cover for gnr as patient now septic. of note, it appears that chronic foley has eroded through the floor of his penis. -urology consult -aztreonam cipro as above . # pressure ulcers: tibia, abdomen, left groin -add on albumin -nutrition consult -wound care consult . #anemia: patient came in at 30, pre-or 29 and then 25 post or. while first unit going in, immediately upon completion. hct checked and 23. some bloood loss in wound vac (several hundred ccs), -2 units prbcs with goal hct >25 or if needed for volume repletion -per ortho will continue lovenox 40 daily for vte ppx given such high risk -if not bumping appropriately, consider dic labs, retic . #multiple sclerosis: holding patient's baclofen, meperidine this am as patient npo. - can consider restarting if patient improves. . # access: 20g and 18g peripheral. # ppx: lovenox # code: full # contact: [**name (ni) 107**] (personal care giver/vna for 4yrs): [**telephone/fax (1) 13462**]. # dispo: icu icu care nutrition: glycemic control: lines: 20 gauge - [**2104-1-25**] 05:37 am prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: full code disposition:",0
312,"59 yo s/p r total knee replacement (uncomplicated) admitted from [** 215**] for monitoring of resp status (hx osa & angioedema following igg administration a year ago). pmh/psh: oa severe, chronic urticaria, steroid induced dm, fibromyalgia, allergic rhinitis, obesity s/p gastric bypass, long qt syndrome, osa but refuses to use cpap, hypothyroidism, cystocele, fld-filled paraspinal mass allergies: sulfa, methadone in [**name (ni) 215**] pt put on ketamine gtt ( via pca pump). patient arrived on cpm @ 0-60 degrees to r knee. note: patient takes own meds which are in clear plastic box in room ( not w/in patient s reach). says she cannot take generic meds provided by hospital, that they may give her an adverse reaction. also, unbleached bed linen used on bed. repleted with 40meq potassium this a.m for a k+ of 3.2, mgso4 4gm iv given for magnesium of 1.4 pt can have meds which is in her person. pharmacy has checked all meds. [**last name 19**] problem [**name (ni) 217**] r total knee replacement [**7-6**] assessment: ace wrap to r knee & leg d&i. b dp s & pt s easily palpable. [**initials (namepattern4) **] [**last name (namepattern4) **] intact but no [**male first name (un) **] stocking on r due to ace wrap to r leg. b pneumo boots in place. hemovac/jp kept @ half compression & drained sanguinous drainage. tmax 99.1 po. started dilaudid pca (.25/10/1.5 mg) @ [**2153**] for c/o r knee pain unrelieved w/basal rate of 10mg/hr ketamine. pain was rated 6 for most of the night. patient was relatively comfortable @ that level. occasionally bumped up to 8. only went up to 10 during blood draw in am when both ketamine & diladid were off for a short time to draw blood. action: removed cpm for night @ 2300. restarted cpm @ 0500. kept pillow between knees. kept towel under r ankle to elevate r heel off bed. no pillow under r knee. patient used is x10 q 1 hr while awake. ice packs applied to r knee all night (refilled q 4 hrs ). cpm stopped at 0800. response: patient c/o intolerable hip (&back) pain when turned side to side despite iv ketamine & dilaudid pca plan: kept patient supine overnight. to get patient up to chair today. .h/o obstructive sleep apnea (osa) assessment: rr 12-21 overnight. o2 sats: 95-98% on 2l np[**md number(3) 218**]: clear to auscultation. refused cpap/bipap w/hx osa. action: monitored o2 sats overnight closely response: o2 sats as above. plan: check o2 sats q 4 hrs h/o back pain assessment: patient has chronic back pain, which she experienced when not supine. r leg [**md number(3) **] pain more intense. refused bedpan for this reason. wants to get up to commode during day. action: received neurontin 300mg x2 in eve & 20mg flexeril po which she chronically takes. not given lunesta (sleeper she usually takes) in presence of anesthesia earlier in day as well as iv ketamine & dilaudid. also not given darvocette. response: lights out by 2315. fell asleep in 15min. slept until awoken @ 0400. plan: continue to position patient as she tolerates & encourage is, c& db. get oob. .h/o [**last name **] problem hx prolonged qt interval w/possible syncope assessment: qtc =.38 hr: 60 s-70s sr no ectopy bp: 90 s-130 action: avoided all possible causes of prolonged qt interval such as low k, low mg, dehydration, starvation, hypothyroidism ( received levothyroxin pre-op), and all meds that could lead to prolonged qt (meds listed @ end of this note, & obtained from up to date response: qt interval remained wnl. hr as above. plan: avoid all possible causes of prolonged qt interval as above list of meds to avoid in front of med book as well. medications that could lead to prolonged qt interval: anti-arrythmics: quinidine, procainamide, disopyramide, amiodarone, sotalol, dofetilide, ibutilide, azimilide, sematilide anti-microbials: erythromycin, clarithromycin, telithromycin, azithromycin (minor), some fluoroquinolones (levofloxacin, moxifloxacin, sparfloxacin, gatifloxacin). other antimicrobials: spiramycin, chloroquin, halofantrine, mefluquine antihistamines: terfenadine, astemizole psychotropics: thioridazine, phenothiazines, tricyclic or tetracyclic antidepressants, haloperidol & other batyrophenones, selective serotonin reuptake inhibitors, risperidone, methadone other drugs: vasodilators:prenylamine, bepridil, mibefradil diuretics: via electrolyte changes ( hypokalemia, low mg) serotonin antagonist: ketanserin motility drugs: cisapride, domperidol droperidol, ranolazine hiv protease inhibitors, organophosphate insecticides, probucol, cocaine, terodiline, papaverine, chloral hydrate, arsenic trioxide (chemo), cesium chloride, levomethadyl.",1
313,"59 yo s/p r total knee replacement (uncomplicated) admitted from [** 215**] for monitoring of resp status (hx osa & angioedema following igg administration a year ago). pmh/psh: oa severe, chronic urticaria, steroid induced dm, fibromyalgia, allergic rhinitis, obesity s/p gastric bypass, long qt syndrome, osa but refuses to use cpap, hypothyroidism, cystocele, fld-filled paraspinal mass allergies: sulfa, methadone in [**name (ni) 215**] pt put on ketamine gtt ( via pca pump). patient arrived on cpm @ 0-60 degrees to r knee. note: patient takes own meds which are in clear plastic box in room ( not w/in patient s reach). says she cannot take generic meds provided by hospital, that they may give her an adverse reaction. also, unbleached bed linen used on bed. repleted with 40meq potassium this a.m for a k+ of 3.2, mgso4 4gm iv given for magnesium of 1.4 pt can have meds which is in her person. pharmacy has checked all meds. [**last name 19**] problem [**name (ni) 217**] r total knee replacement [**7-6**] assessment: ace wrap to r knee & leg d&i. b dp s & pt s easily palpable. [**initials (namepattern4) **] [**last name (namepattern4) **] intact but no [**male first name (un) **] stocking on r due to ace wrap to r leg. b pneumo boots in place. hemovac/jp kept @ half compression & drained sanguinous drainage. tmax 99.1 po. started dilaudid pca (.25/10/1.5 mg) @ [**2153**] for c/o r knee pain unrelieved w/basal rate of 10mg/hr ketamine. pain was rated 6 for most of the night. patient was relatively comfortable @ that level. occasionally bumped up to 8. only went up to 10 during blood draw in am when both ketamine & diladid were off for a short time to draw blood. action: removed cpm for night @ 2300. restarted cpm @ 0500. kept pillow between knees. kept towel under r ankle to elevate r heel off bed. no pillow under r knee. patient used is x10 q 1 hr while awake. ice packs applied to r knee all night (refilled q 4 hrs ). cpm stopped at 0800. response: patient c/o intolerable hip (&back) pain when turned side to side despite iv ketamine & dilaudid pca plan: kept patient supine overnight. to get patient up to chair today. .h/o obstructive sleep apnea (osa) assessment: rr 12-21 overnight. o2 sats: 95-98% on 2l np[**md number(3) 218**]: clear to auscultation. refused cpap/bipap w/hx osa. action: monitored o2 sats overnight closely response: o2 sats as above. plan: check o2 sats q 4 hrs h/o back pain assessment: patient has chronic back pain, which she experienced when not supine. r leg [**md number(3) **] pain more intense. refused bedpan for this reason. wants to get up to commode during day. action: received neurontin 300mg x2 in eve & 20mg flexeril po which she chronically takes. not given lunesta (sleeper she usually takes) in presence of anesthesia earlier in day as well as iv ketamine & dilaudid. also not given darvocette. response: lights out by 2315. fell asleep in 15min. slept until awoken @ 0400. plan: continue to position patient as she tolerates & encourage is, c& db. get oob. .h/o [**last name **] problem hx prolonged qt interval w/possible syncope assessment: qtc =.38 hr: 60 s-70s sr no ectopy bp: 90 s-130 action: avoided all possible causes of prolonged qt interval such as low k, low mg, dehydration, starvation, hypothyroidism ( received levothyroxin pre-op), and all meds that could lead to prolonged qt (meds listed @ end of this note, & obtained from up to date response: qt interval remained wnl. hr as above. plan: avoid all possible causes of prolonged qt interval as above list of meds to avoid in front of med book as well. medications that could lead to prolonged qt interval: anti-arrythmics: quinidine, procainamide, disopyramide, amiodarone, sotalol, dofetilide, ibutilide, azimilide, sematilide anti-microbials: erythromycin, clarithromycin, telithromycin, azithromycin (minor), some fluoroquinolones (levofloxacin, moxifloxacin, sparfloxacin, gatifloxacin). other antimicrobials: spiramycin, chloroquin, halofantrine, mefluquine antihistamines: terfenadine, astemizole psychotropics: thioridazine, phenothiazines, tricyclic or tetracyclic antidepressants, haloperidol & other batyrophenones, selective serotonin reuptake inhibitors, risperidone, methadone other drugs: vasodilators:prenylamine, bepridil, mibefradil diuretics: via electrolyte changes ( hypokalemia, low mg) serotonin antagonist: ketanserin motility drugs: cisapride, domperidol droperidol, ranolazine hiv protease inhibitors, organophosphate insecticides, probucol, cocaine, terodiline, papaverine, chloral hydrate, arsenic trioxide (chemo), cesium chloride, levomethadyl. demographics attending md: admit diagnosis: code status: height: admission weight: daily weight: allergies/reactions: precautions: pmh: cv-pmh: additional history: surgery / procedure and date: latest vital signs and i/o non-invasive bp: s: d: temperature: arterial bp: s: d: respiratory rate: heart rate: heart rhythm: o2 delivery device: o2 saturation: o2 flow: fio2 set: 24h total in: 24h total out: pacer data pertinent lab results: additional pertinent labs: lines / tubes / drains: valuables / signature patient valuables: other valuables: clothes: wallet / money: cash / credit cards sent home with: jewelry: transferred from: transferred to: date & time of transfer:",1
314,"59 yo s/p r total knee replacement (uncomplicated) admitted from [** 215**] for monitoring of resp status (hx osa & angioedema following igg administration a year ago). pmh/psh: oa severe, chronic urticaria, steroid induced dm, fibromyalgia, allergic rhinitis, obesity s/p gastric bypass, long qt syndrome, osa but refuses to use cpap, hypothyroidism, cystocele, fld-filled paraspinal mass allergies: sulfa, methadone in [**name (ni) 215**] pt put on ketamine gtt ( via pca pump). patient arrived on cpm @ 0-60 degrees to r knee. note: patient takes own meds which are in clear plastic box in room ( not w/in patient s reach). says she cannot take generic meds provided by hospital, that they may give her an adverse reaction. also, unbleached bed linen used on bed. repleted with 40meq potassium this a.m for a k+ of 3.2, mgso4 4gm iv given for magnesium of 1.4 pt can have meds which is in her person. pharmacy has checked all meds. fsbs at 1200 187, pt refused s/c insulin regular 2 units [**last name 19**] problem [**name (ni) 217**] r total knee replacement [**7-6**] assessment: ace wrap to r knee & leg d&i. b dp s & pt s easily palpable. [**initials (namepattern4) **] [**last name (namepattern4) **] intact but no [**male first name (un) **] stocking on r due to ace wrap to r leg. b pneumo boots in place. hemovac/jp kept @ half compression & drained sanguinous drainage. tmax 99.1 po. started dilaudid pca (.25/10/1.5 mg) @ [**2153**] for c/o r knee pain unrelieved w/basal rate of 10mg/hr ketamine. pain was rated 6 for most of the night. patient was relatively comfortable @ that level. occasionally bumped up to 8. only went up to 10 during blood draw in am when both ketamine & diladid were off for a short time to draw blood. action: removed cpm for night @ 2300. restarted cpm @ 0500. kept pillow between knees. kept towel under r ankle to elevate r heel off bed. no pillow under r knee. patient used is x10 q 1 hr while awake. ice packs applied to r knee all night (refilled q 4 hrs ). cpm stopped at 0800. response: patient c/o intolerable hip (&back) pain when turned side to side despite iv ketamine & dilaudid pca plan: kept patient supine overnight. to get patient up to chair today. .h/o obstructive sleep apnea (osa) assessment: rr 12-21 overnight. o2 sats: 95-98% on 2l np[**md number(3) 218**]: clear to auscultation. refused cpap/bipap w/hx osa. action: monitored o2 sats overnight closely response: o2 sats as above. plan: check o2 sats q 4 hrs h/o back pain assessment: patient has chronic back pain, which she experienced when not supine. r leg [**md number(3) **] pain more intense. refused bedpan for this reason. wants to get up to commode during day. action: received neurontin 300mg x2 in eve & 20mg flexeril po which she chronically takes. not given lunesta (sleeper she usually takes) in presence of anesthesia earlier in day as well as iv ketamine & dilaudid. also not given darvocette. response: lights out by 2315. fell asleep in 15min. slept until awoken @ 0400. plan: continue to position patient as she tolerates & encourage is, c& db. get oob. .h/o [**last name **] problem hx prolonged qt interval w/possible syncope assessment: qtc =.38 hr: 60 s-70s sr no ectopy bp: 90 s-130 action: avoided all possible causes of prolonged qt interval such as low k, low mg, dehydration, starvation, hypothyroidism ( received levothyroxin pre-op), and all meds that could lead to prolonged qt (meds listed @ end of this note, & obtained from up to date response: qt interval remained wnl. hr as above. plan: avoid all possible causes of prolonged qt interval as above list of meds to avoid in front of med book as well. medications that could lead to prolonged qt interval: anti-arrythmics: quinidine, procainamide, disopyramide, amiodarone, sotalol, dofetilide, ibutilide, azimilide, sematilide anti-microbials: erythromycin, clarithromycin, telithromycin, azithromycin (minor), some fluoroquinolones (levofloxacin, moxifloxacin, sparfloxacin, gatifloxacin). other antimicrobials: spiramycin, chloroquin, halofantrine, mefluquine antihistamines: terfenadine, astemizole psychotropics: thioridazine, phenothiazines, tricyclic or tetracyclic antidepressants, haloperidol & other batyrophenones, selective serotonin reuptake inhibitors, risperidone, methadone other drugs: vasodilators:prenylamine, bepridil, mibefradil diuretics: via electrolyte changes ( hypokalemia, low mg) serotonin antagonist: ketanserin motility drugs: cisapride, domperidol droperidol, ranolazine hiv protease inhibitors, organophosphate insecticides, probucol, cocaine, terodiline, papaverine, chloral hydrate, arsenic trioxide (chemo), cesium chloride, levomethadyl. demographics attending md: [**doctor last name 224**] [**location (un) 225**] k. admit diagnosis: right knee oa/sda code status: full code height: 64 inch admission weight: 114.5 kg daily weight: allergies/reactions: sulfa (sulfonamides) unknown; methadone seizures; precautions: pmh: cv-pmh: additional history: hypothyroidism, prolonged qt, s/p gastric bipass, arthritis, knee replacement fibromyalgia, obstructive sleep apnea, recent admission [**10-22**] with severe urticaria/anigioedema tx with ivig surgery / procedure and date: rt total knee replacement [**2162-7-6**] latest vital signs and i/o non-invasive bp: s:111 d:58 temperature: 98.5 arterial bp: s: d: respiratory rate: 18 insp/min heart rate: 68 bpm heart rhythm: sr (sinus rhythm) o2 delivery device: nasal cannula o2 saturation: 98% % o2 flow: 2 l/min fio2 set: 24h total in: 1,192 ml 24h total out: 1,570 ml pertinent lab results: sodium: 140 meq/l [**2162-7-7**] 03:25 am potassium: 3.2 meq/l [**2162-7-7**] 03:25 am chloride: 109 meq/l [**2162-7-7**] 03:25 am co2: 22 meq/l [**2162-7-7**] 03:25 am bun: 6 mg/dl [**2162-7-7**] 03:25 am creatinine: 0.5 mg/dl [**2162-7-7**] 03:25 am glucose: 100 mg/dl [**2162-7-7**] 03:25 am hematocrit: 27.1 % [**2162-7-7**] 03:25 am finger stick glucose: 187 [**2162-7-7**] 12:00 pm additional pertinent labs: lines / tubes / drains: 2 piv in l arm valuables / signature patient valuables: glasses other valuables: a pair of shoes, some clothes, a pocket book clothes: transferred with patient wallet / money: no money / wallet cash / credit cards sent home with: jewelry: transferred from: [**hospital ward name 77**] 4 [**hospital **] transferred to: 1276 date & time of transfer: [**2162-7-7**] 12:00 am",1
315,"59 yo s/p r total knee replacement (uncomplicated) admitted from [** 215**] for monitoring of resp status (hx osa & angioedema following igg administration a year ago). pmh/psh: oa severe, chronic urticaria, steroid induced dm, fibromyalgia, allergic rhinitis, obesity s/p gastric bypass, long qt syndrome, osa but refuses to use cpap, hypothyroidism, cystocele, fld-filled paraspinal mass allergies: sulfa, methadone in [**name (ni) 215**] pt put on ketamine gtt ( via pca pump). patient arrived on cpm @ 0-60 degrees to r knee. note: patient takes own meds which are in clear plastic box in room ( not w/in patient s reach). says she cannot take generic meds provided by hospital, that they may give her an adverse reaction. also, unbleached bed linen used on bed. repleted with 40meq potassium this a.m for a k+ of 3.2, mgso4 4gm iv given for magnesium of 1.4 pt can have meds which is in her person. pharmacy has checked all meds. fsbs at 1200 187, pt refused s/c insulin regular 2 units [**last name 19**] problem [**name (ni) 217**] r total knee replacement [**7-6**] assessment: ace wrap to r knee & leg d&i. b dp s & pt s easily palpable. [**initials (namepattern4) **] [**last name (namepattern4) **] intact but no [**male first name (un) **] stocking on r due to ace wrap to r leg. b pneumo boots in place. hemovac/jp kept @ half compression & drained sanguinous drainage. tmax 99.1 po. started dilaudid pca (.25/10/1.5 mg) @ [**2153**] for c/o r knee pain unrelieved w/basal rate of 10mg/hr ketamine. pain was rated 6 for most of the night. patient was relatively comfortable @ that level. occasionally bumped up to 8. only went up to 10 during blood draw in am when both ketamine & diladid were off for a short time to draw blood. action: removed cpm for night @ 2300. restarted cpm @ 0500. kept pillow between knees. kept towel under r ankle to elevate r heel off bed. no pillow under r knee. patient used is x10 q 1 hr while awake. ice packs applied to r knee all night (refilled q 4 hrs ). cpm stopped at 0800. response: patient c/o intolerable hip (&back) pain when turned side to side despite iv ketamine & dilaudid pca plan: kept patient supine overnight. to get patient up to chair today. .h/o obstructive sleep apnea (osa) assessment: rr 12-21 overnight. o2 sats: 95-98% on 2l np[**md number(3) 218**]: clear to auscultation. refused cpap/bipap w/hx osa. action: monitored o2 sats overnight closely response: o2 sats as above. plan: check o2 sats q 4 hrs h/o back pain assessment: patient has chronic back pain, which she experienced when not supine. r leg [**md number(3) **] pain more intense. refused bedpan for this reason. wants to get up to commode during day. action: received neurontin 300mg x2 in eve & 20mg flexeril po which she chronically takes. not given lunesta (sleeper she usually takes) in presence of anesthesia earlier in day as well as iv ketamine & dilaudid. also not given darvocette. response: lights out by 2315. fell asleep in 15min. slept until awoken @ 0400. plan: continue to position patient as she tolerates & encourage is, c& db. get oob. .h/o [**last name **] problem hx prolonged qt interval w/possible syncope assessment: qtc =.38 hr: 60 s-70s sr no ectopy bp: 90 s-130 action: avoided all possible causes of prolonged qt interval such as low k, low mg, dehydration, starvation, hypothyroidism ( received levothyroxin pre-op), and all meds that could lead to prolonged qt (meds listed @ end of this note, & obtained from up to date response: qt interval remained wnl. hr as above. plan: avoid all possible causes of prolonged qt interval as above list of meds to avoid in front of med book as well. medications that could lead to prolonged qt interval: anti-arrythmics: quinidine, procainamide, disopyramide, amiodarone, sotalol, dofetilide, ibutilide, azimilide, sematilide anti-microbials: erythromycin, clarithromycin, telithromycin, azithromycin (minor), some fluoroquinolones (levofloxacin, moxifloxacin, sparfloxacin, gatifloxacin). other antimicrobials: spiramycin, chloroquin, halofantrine, mefluquine antihistamines: terfenadine, astemizole psychotropics: thioridazine, phenothiazines, tricyclic or tetracyclic antidepressants, haloperidol & other batyrophenones, selective serotonin reuptake inhibitors, risperidone, methadone other drugs: vasodilators:prenylamine, bepridil, mibefradil diuretics: via electrolyte changes ( hypokalemia, low mg) serotonin antagonist: ketanserin motility drugs: cisapride, domperidol droperidol, ranolazine hiv protease inhibitors, organophosphate insecticides, probucol, cocaine, terodiline, papaverine, chloral hydrate, arsenic trioxide (chemo), cesium chloride, levomethadyl. demographics attending md: [**doctor last name 224**] [**location (un) 225**] k. admit diagnosis: right knee oa/sda code status: full code height: 64 inch admission weight: 114.5 kg daily weight: allergies/reactions: sulfa (sulfonamides) unknown; methadone seizures; precautions: pmh: cv-pmh: additional history: hypothyroidism, prolonged qt, s/p gastric bipass, arthritis, knee replacement fibromyalgia, obstructive sleep apnea, recent admission [**10-22**] with severe urticaria/anigioedema tx with ivig surgery / procedure and date: rt total knee replacement [**2162-7-6**] latest vital signs and i/o non-invasive bp: s:111 d:58 temperature: 98.5 arterial bp: s: d: respiratory rate: 18 insp/min heart rate: 68 bpm heart rhythm: sr (sinus rhythm) o2 delivery device: nasal cannula o2 saturation: 98% % o2 flow: 2 l/min fio2 set: 24h total in: 1,192 ml 24h total out: 1,570 ml pertinent lab results: sodium: 140 meq/l [**2162-7-7**] 03:25 am potassium: 3.2 meq/l [**2162-7-7**] 03:25 am chloride: 109 meq/l [**2162-7-7**] 03:25 am co2: 22 meq/l [**2162-7-7**] 03:25 am bun: 6 mg/dl [**2162-7-7**] 03:25 am creatinine: 0.5 mg/dl [**2162-7-7**] 03:25 am glucose: 100 mg/dl [**2162-7-7**] 03:25 am hematocrit: 27.1 % [**2162-7-7**] 03:25 am finger stick glucose: 187 [**2162-7-7**] 12:00 pm additional pertinent labs: lines / tubes / drains: 2 piv in l arm ( one 18 and one 22 ) valuables / signature patient valuables: glasses other valuables: a pair of shoes, some clothes, a pocket book clothes: transferred with patient wallet / money: no money / wallet cash / credit cards sent home with: jewelry: transferred from: [**hospital ward name 77**] 4 [**hospital **] transferred to: 1276 date & time of transfer: [**2162-7-7**] 12:00 am",1
316,"59 yo s/p r total knee replacement (uncomplicated) admitted from [** 215**] for monitoring of resp status (hx osa & angioedema following igg administration a year ago). pmh/psh: oa severe, chronic urticaria, steroid induced dm, fibromyalgia, allergic rhinitis, obesity s/p gastric bypass, long qt syndrome, osa but refuses to use cpap, hypothyroidism, cystocele, fld-filled paraspinal mass allergies: sulfa, methadone in [**name (ni) 215**] pt put on ketamine gtt ( via pca pump). patient arrived on cpm @ 0-60 degrees to r knee. note: patient takes own meds which are in clear plastic box in room ( not w/in patient s reach). says she cannot take generic meds provided by hospital, that they may give her an adverse reaction. also, unbleached bed linen used on bed. repleted with 40meq potassium this a.m for a k+ of 3.2, mgso4 4gm iv given for magnesium of 1.4 pt can have meds which is in her person. pharmacy has checked all meds. fsbs at 1200 187, pt refused s/c insulin regular 2 units. pt is on pca pump ( dilaudid 0.25 mg , lock time 10 [**last name (lf) 226**], [**first name3 (lf) **] of 1.5 mg/hr), pt received 0.25 mg at 0900, 1000, 1100, 1200. on ketamine infusion 5-15mg/hr iv infusion at 10mg/hr [**last name 19**] problem [**name (ni) 217**] r total knee replacement [**7-6**] assessment: ace wrap to r knee & leg d&i. b dp s & pt s easily palpable. [**initials (namepattern4) **] [**last name (namepattern4) **] intact but no [**male first name (un) **] stocking on r due to ace wrap to r leg. b pneumo boots in place. hemovac/jp kept @ half compression & drained sanguinous drainage. tmax 99.1 po. started dilaudid pca (.25/10/1.5 mg) @ [**2153**] for c/o r knee pain unrelieved w/basal rate of 10mg/hr ketamine. pain was rated 6 for most of the night. patient was relatively comfortable @ that level. occasionally bumped up to 8. only went up to 10 during blood draw in am when both ketamine & diladid were off for a short time to draw blood. action: removed cpm for night @ 2300. restarted cpm @ 0500. kept pillow between knees. kept towel under r ankle to elevate r heel off bed. no pillow under r knee. patient used is x10 q 1 hr while awake. ice packs applied to r knee all night (refilled q 4 hrs ). cpm stopped at 0800. response: patient c/o intolerable hip (&back) pain when turned side to side despite iv ketamine & dilaudid pca plan: kept patient supine overnight. to get patient up to chair today. .h/o obstructive sleep apnea (osa) assessment: rr 12-21 overnight. o2 sats: 95-98% on 2l np[**md number(3) 218**]: clear to auscultation. refused cpap/bipap w/hx osa. action: monitored o2 sats overnight closely response: o2 sats as above. plan: check o2 sats q 4 hrs h/o back pain assessment: patient has chronic back pain, which she experienced when not supine. r leg [**md number(3) **] pain more intense. refused bedpan for this reason. wants to get up to commode during day. action: received neurontin 300mg x2 in eve & 20mg flexeril po which she chronically takes. not given lunesta (sleeper she usually takes) in presence of anesthesia earlier in day as well as iv ketamine & dilaudid. also not given darvocette. response: lights out by 2315. fell asleep in 15min. slept until awoken @ 0400. plan: continue to position patient as she tolerates & encourage is, c& db. get oob. .h/o [**last name **] problem hx prolonged qt interval w/possible syncope assessment: qtc =.38 hr: 60 s-70s sr no ectopy bp: 90 s-130 action: avoided all possible causes of prolonged qt interval such as low k, low mg, dehydration, starvation, hypothyroidism ( received levothyroxin pre-op), and all meds that could lead to prolonged qt (meds listed @ end of this note, & obtained from up to date response: qt interval remained wnl. hr as above. plan: avoid all possible causes of prolonged qt interval as above list of meds to avoid in front of med book as well. medications that could lead to prolonged qt interval: anti-arrythmics: quinidine, procainamide, disopyramide, amiodarone, sotalol, dofetilide, ibutilide, azimilide, sematilide anti-microbials: erythromycin, clarithromycin, telithromycin, azithromycin (minor), some fluoroquinolones (levofloxacin, moxifloxacin, sparfloxacin, gatifloxacin). other antimicrobials: spiramycin, chloroquin, halofantrine, mefluquine antihistamines: terfenadine, astemizole psychotropics: thioridazine, phenothiazines, tricyclic or tetracyclic antidepressants, haloperidol & other batyrophenones, selective serotonin reuptake inhibitors, risperidone, methadone other drugs: vasodilators:prenylamine, bepridil, mibefradil diuretics: via electrolyte changes ( hypokalemia, low mg) serotonin antagonist: ketanserin motility drugs: cisapride, domperidol droperidol, ranolazine hiv protease inhibitors, organophosphate insecticides, probucol, cocaine, terodiline, papaverine, chloral hydrate, arsenic trioxide (chemo), cesium chloride, levomethadyl. demographics attending md: [**doctor last name 224**] [**location (un) 225**] k. admit diagnosis: right knee oa/sda code status: full code height: 64 inch admission weight: 114.5 kg daily weight: allergies/reactions: sulfa (sulfonamides) unknown; methadone seizures; precautions: pmh: cv-pmh: additional history: hypothyroidism, prolonged qt, s/p gastric bipass, arthritis, knee replacement fibromyalgia, obstructive sleep apnea, recent admission [**10-22**] with severe urticaria/anigioedema tx with ivig surgery / procedure and date: rt total knee replacement [**2162-7-6**] latest vital signs and i/o non-invasive bp: s:111 d:58 temperature: 98.5 arterial bp: s: d: respiratory rate: 18 insp/min heart rate: 68 bpm heart rhythm: sr (sinus rhythm) o2 delivery device: nasal cannula o2 saturation: 98% % o2 flow: 2 l/min fio2 set: 24h total in: 1,192 ml 24h total out: 1,570 ml pertinent lab results: sodium: 140 meq/l [**2162-7-7**] 03:25 am potassium: 3.2 meq/l [**2162-7-7**] 03:25 am chloride: 109 meq/l [**2162-7-7**] 03:25 am co2: 22 meq/l [**2162-7-7**] 03:25 am bun: 6 mg/dl [**2162-7-7**] 03:25 am creatinine: 0.5 mg/dl [**2162-7-7**] 03:25 am glucose: 100 mg/dl [**2162-7-7**] 03:25 am hematocrit: 27.1 % [**2162-7-7**] 03:25 am finger stick glucose: 187 [**2162-7-7**] 12:00 pm additional pertinent labs: lines / tubes / drains: 2 piv in l arm ( one 18 and one 22 ) valuables / signature patient valuables: glasses other valuables: a pair of shoes, some clothes, a pocket book clothes: transferred with patient wallet / money: pt has a pocket book, says she has $ 7. cash / credit cards sent home with: jewelry: transferred from: [**hospital ward name 77**] 4 [**hospital **] transferred to: 1276 date & time of transfer: [**2162-7-7**] 12:00 am",1
317,"59 yo s/p r total knee replacement (uncomplicated) admitted from [** 215**] for monitoring of resp status (hx osa & angioedema following igg administration a year ago). pmh/psh: oa severe, chronic urticaria, steroid induced dm, fibromyalgia, allergic rhinitis, obesity s/p gastric bypass, long qt syndrome, osa but refuses to use cpap, hypothyroidism, cystocele, fld-filled paraspinal mass allergies: sulfa, methadone in [**name (ni) 215**] pt put on ketamine gtt ( via pca pump). patient arrived on cpm @ 0-60 degrees to r knee. note: patient takes own meds which are in clear plastic box in room ( not w/in patient s reach). says she cannot take generic meds provided by hospital, that they may give her an adverse reaction. also, unbleached bed linen used on bed. repleted with 40meq potassium this a.m for a k+ of 3.2, mgso4 4gm iv given for magnesium of 1.4 pt can have meds which is in her person. pharmacy has checked all meds. fsbs at 1200 187, pt refused s/c insulin regular 2 units. pt is on pca pump ( dilaudid 0.25 mg , lock time 10 [**last name (lf) 226**], [**first name3 (lf) **] of 1.5 mg/hr), pt received total of 1mg since the start of the shift. on ketamine infusion 5-15mg/hr iv infusion at 10mg/hr [**last name 19**] problem [**name (ni) 217**] r total knee replacement [**7-6**] assessment: ace wrap to r knee & leg d&i. b dp s & pt s easily palpable. [**initials (namepattern4) **] [**last name (namepattern4) **] intact but no [**male first name (un) **] stocking on r due to ace wrap to r leg. b pneumo boots in place. hemovac/jp kept @ half compression & drained sanguinous drainage. tmax 99.1 po. started dilaudid pca (.25/10/1.5 mg) @ [**2153**] for c/o r knee pain unrelieved w/basal rate of 10mg/hr ketamine. pain was rated 6 for most of the night. patient was relatively comfortable @ that level. occasionally bumped up to 8. only went up to 10 during blood draw in am when both ketamine & diladid were off for a short time to draw blood. action: removed cpm for night @ 2300. restarted cpm @ 0500. kept pillow between knees. kept towel under r ankle to elevate r heel off bed. no pillow under r knee. patient used is x10 q 1 hr while awake. ice packs applied to r knee all night (refilled q 4 hrs ). cpm stopped at 0800. response: patient c/o intolerable hip (&back) pain when turned side to side despite iv ketamine & dilaudid pca plan: kept patient supine overnight. to get patient up to chair today. .h/o obstructive sleep apnea (osa) assessment: rr 12-21 overnight. o2 sats: 95-98% on 2l np[**md number(3) 218**]: clear to auscultation. refused cpap/bipap w/hx osa. action: monitored o2 sats overnight closely response: o2 sats as above. plan: check o2 sats q 4 hrs h/o back pain assessment: patient has chronic back pain, which she experienced when not supine. r leg [**md number(3) **] pain more intense. refused bedpan for this reason. wants to get up to commode during day. action: received neurontin 300mg x2 in eve & 20mg flexeril po which she chronically takes. not given lunesta (sleeper she usually takes) in presence of anesthesia earlier in day as well as iv ketamine & dilaudid. also not given darvocette. response: lights out by 2315. fell asleep in 15min. slept until awoken @ 0400. plan: continue to position patient as she tolerates & encourage is, c& db. get oob upon ortho approval, pt consult needed. .h/o [**last name **] problem hx prolonged qt interval w/possible syncope assessment: qtc =.38 hr: 60 s-70s sr no ectopy bp: 90 s-130 action: avoided all possible causes of prolonged qt interval such as low k, low mg, dehydration, starvation, hypothyroidism ( received levothyroxin pre-op), and all meds that could lead to prolonged qt (meds listed @ end of this note, & obtained from up to date response: qt interval remained wnl. hr as above. plan: avoid all possible causes of prolonged qt interval as above list of meds to avoid in front of med book as well. medications that could lead to prolonged qt interval: anti-arrythmics: quinidine, procainamide, disopyramide, amiodarone, sotalol, dofetilide, ibutilide, azimilide, sematilide anti-microbials: erythromycin, clarithromycin, telithromycin, azithromycin (minor), some fluoroquinolones (levofloxacin, moxifloxacin, sparfloxacin, gatifloxacin). other antimicrobials: spiramycin, chloroquin, halofantrine, mefluquine antihistamines: terfenadine, astemizole psychotropics: thioridazine, phenothiazines, tricyclic or tetracyclic antidepressants, haloperidol & other batyrophenones, selective serotonin reuptake inhibitors, risperidone, methadone other drugs: vasodilators:prenylamine, bepridil, mibefradil diuretics: via electrolyte changes ( hypokalemia, low mg) serotonin antagonist: ketanserin motility drugs: cisapride, domperidol droperidol, ranolazine hiv protease inhibitors, organophosphate insecticides, probucol, cocaine, terodiline, papaverine, chloral hydrate, arsenic trioxide (chemo), cesium chloride, levomethadyl. demographics attending md: [**doctor last name 224**] [**location (un) 225**] k. admit diagnosis: right knee oa/sda code status: full code height: 64 inch admission weight: 114.5 kg daily weight: allergies/reactions: sulfa (sulfonamides) unknown; methadone seizures; precautions: pmh: cv-pmh: additional history: hypothyroidism, prolonged qt, s/p gastric bipass, arthritis, knee replacement fibromyalgia, obstructive sleep apnea, recent admission [**10-22**] with severe urticaria/anigioedema tx with ivig surgery / procedure and date: rt total knee replacement [**2162-7-6**] latest vital signs and i/o non-invasive bp: s:111 d:58 temperature: 98.5 arterial bp: s: d: respiratory rate: 18 insp/min heart rate: 68 bpm heart rhythm: sr (sinus rhythm) o2 delivery device: nasal cannula o2 saturation: 98% % o2 flow: 2 l/min fio2 set: 24h total in: 1,192 ml 24h total out: 1,570 ml pertinent lab results: sodium: 140 meq/l [**2162-7-7**] 03:25 am potassium: 3.2 meq/l [**2162-7-7**] 03:25 am chloride: 109 meq/l [**2162-7-7**] 03:25 am co2: 22 meq/l [**2162-7-7**] 03:25 am bun: 6 mg/dl [**2162-7-7**] 03:25 am creatinine: 0.5 mg/dl [**2162-7-7**] 03:25 am glucose: 100 mg/dl [**2162-7-7**] 03:25 am hematocrit: 27.1 % [**2162-7-7**] 03:25 am finger stick glucose: 187 [**2162-7-7**] 12:00 pm additional pertinent labs: lines / tubes / drains: 2 piv in l arm ( one 18 and one 22 ) valuables / signature patient valuables: glasses other valuables: a pair of shoes, some clothes, a pocket book clothes: transferred with patient wallet / money: pt has a pocket book, says she has $ 7. cash / credit cards sent home with: jewelry: transferred from: [**hospital ward name 77**] 4 [**hospital **] transferred to: 1276 date & time of transfer: [**2162-7-7**] 12:00 am",1
318,"59 yo s/p r total knee replacement (uncomplicated) admitted from [** 215**] for monitoring of resp status (hx osa & angioedema following igg administration a year ago). pmh/psh: oa severe, chronic urticaria, steroid induced dm, fibromyalgia, allergic rhinitis, obesity s/p gastric bypass, long qt syndrome, osa but refuses to use cpap, hypothyroidism, cystocele, fld-filled paraspinal mass allergies: sulfa, methadone in [**name (ni) 215**] pt put on ketamine gtt ( via pca pump). patient arrived on cpm @ 0-60 degrees to r knee. note: patient takes own meds which are in clear plastic box in room ( not w/in patient s reach). says she cannot take generic meds provided by hospital, that they may give her an adverse reaction. [**last name 19**] problem [**name (ni) 217**] r total knee replacement [**7-6**] assessment: ace wrap to r knee & leg d&i. b dp s & pt s easily palpable. [**initials (namepattern4) **] [**last name (namepattern4) **] intact but no [**male first name (un) **] stocking on r due to ace wrap to r leg. b pneumo boots in place. hemovac/jp kept @ half compression & drained 170cc sanguinous drainage from 1900-0000. tmax 99.1 po. started dilaudid pca (.25/10/1.5 mg) @ [**2153**] for c/o r knee pain unrelieved w/basal rate of 10mg/hr ketamine. action: removed cpm for night @ 2300. kept pillow between knees. kept towel under r ankle to elevate r heel off bed. no pillow under r knee. patient used is x10 q 1 hr while awake. response: patient c/o intolerable hip (&back) pain when turned side to side despite iv ketamine & dilaudid pca plan: kept patient supine overnight. .h/o obstructive sleep apnea (osa) assessment: rr 12-21 overnight. o2 sats: 95-98% on 2l np[**md number(3) 218**]: clear to auscultation. refused bipap w/hx osa. action: patient required continuous o2 sat monitoring in presence of ketamine & dilaudid for pain as well as osa response: o2 sats as above. plan: transfer patient to floor in am [**7-7**] .h/o back pain assessment: patient has chronic back pain, which she experienced when not supine. r leg [**month/year (2) **] pain more intense. refused bedpan for this reason. action: received neurontin 300mg x2 in eve & 20mg flexeril po which she chronically takes. not given lunesta (sleeper she usually takes) in presence of anesthesia earlier in day as well as iv ketamine & dilaudid. also not given darvocette. response: lights out by 2315. fell asleep in 15min. plan: continue to position patient as she tolerates & encourage is, c& db. .h/o [**last name **] problem hx prolonged qt interval w/possible syncope assessment: qtc =.38 hr: 60 s-70s sr no ectopy bp: 90 s-130 action: avoided all possible causes of prolonged qt interval such as low k, low mg, dehydration, starvation, hypothyroidism ( received levothyroxin pre-op), and all meds that could lead to prolonged qt (meds listed @ end of this note, & obtained from up to date response: qt interval remained wnl. hr as above. plan: avoid all possible causes of prolonged qt interval as above list of meds to avoid in front of med book as well. medications that could lead to prolonged qt interval: anti-arrythmics: quinidine, procainamide, disopyramide, amiodarone, sotalol, dofetilide, ibutilide, azimilide, sematilide anti-microbials: erythromycin, clarithromycin, telithromycin, azithromycin (minor), some fluoroquinolones (levofloxacin, moxifloxacin, sparfloxacin, gatifloxacin). other antimicrobials: spiramycin, chloroquin, halofantrine, mefluquine antihistamines: terfenadine, astemizole psychotropics: thioridazine, phenothiazines, tricyclic or tetracyclic antidepressants, haloperidol & other batyrophenones, selective serotonin reuptake inhibitors, risperidone, methadone other drugs: vasodilators:prenylamine, bepridil, mibefradil diuretics: via electrolyte changes ( hypokalemia, low mg) serotonin antagonist: ketanserin motility drugs: cisapride, domperidol droperidol, ranolazine hiv protease inhibitors, organophosphate insecticides, probucol, cocaine, terodiline, papaverine, chloral hydrate, arsenic trioxide (chemo), cesium chloride, levomethadyl.",1
319,"59 yo s/p r total knee replacement (uncomplicated) admitted from [** 215**] for monitoring of resp status (hx osa & angioedema following igg administration a year ago). pmh/psh: oa severe, chronic urticaria, steroid induced dm, fibromyalgia, allergic rhinitis, obesity s/p gastric bypass, long qt syndrome, osa but refuses to use cpap, hypothyroidism, cystocele, fld-filled paraspinal mass allergies: sulfa, methadone in [**name (ni) 215**] pt put on ketamine gtt ( via pca pump). patient arrived on cpm @ 0-60 degrees to r knee. note: patient takes own meds which are in clear plastic box in room ( not w/in patient s reach). says she cannot take generic meds provided by hospital, that they may give her an adverse reaction",1
320,"59 yo s/p r total knee replacement (uncomplicated) admitted from [** 215**] for monitoring of resp status (hx osa & angioedema following igg administration a year ago). pmh/psh: oa severe, chronic urticaria, steroid induced dm, fibromyalgia, allergic rhinitis, obesity s/p gastric bypass, long qt syndrome, osa but refuses to use cpap, hypothyroidism, cystocele, fld-filled paraspinal mass allergies: sulfa, methadone in [**name (ni) 215**] pt put on ketamine gtt ( via pca pump). patient arrived on cpm @ 0-60 degrees to r knee. note: patient takes own meds which are in clear plastic box in room ( not w/in patient s reach). says she cannot take generic meds provided by hospital, that they may give her an adverse reaction [**last name 19**] problem [**name (ni) 217**] r total knee replacement [**7-6**] assessment: ace wrap to r knee & leg d&i. b dp s & pt s easily palpable. [**initials (namepattern4) **] [**last name (namepattern4) **] intact but no [**male first name (un) **] stocking on r due to ace wrap to r leg. b pneumo boots in place. hemovac/jp kept @ half compression & drained sanguinous drainage. tmax 99.1 po. started dilaudid pca (.25/10/1.5 mg) @ [**2153**] for c/o r knee pain unrelieved w/basal rate of 10mg/hr ketamine. action: removed cpm for night @ 2300. kept pillow between knees. kept towel under r ankle to elevate r heel off bed. no pillow under r knee. patient used is x10 q 1 hr while awake. response: patient c/o intolerable hip (&back) pain when turned side to side despite iv ketamine & dilaudid pca plan: kept patient supine overnight. to get patient up to chair today. .h/o obstructive sleep apnea (osa) assessment: rr 12-21 overnight. o2 sats: 95-98% on 2l np[**md number(3) 218**]: clear to auscultation. refused bipap w/hx osa. action: monitored o2 sats overnight closely response: o2 sats as above. plan: check o2 sats q 4 hrs",1
321,"59 yo s/p r total knee replacement (uncomplicated) admitted from [** 215**] for monitoring of resp status (hx osa & angioedema following igg administration a year ago). pmh/psh: oa severe, chronic urticaria, steroid induced dm, fibromyalgia, allergic rhinitis, obesity s/p gastric bypass, long qt syndrome, osa but refuses to use cpap, hypothyroidism, cystocele, fld-filled paraspinal mass allergies: sulfa, methadone in [**name (ni) 215**] pt put on ketamine gtt ( via pca pump). patient arrived on cpm @ 0-60 degrees to r knee. note: patient takes own meds which are in clear plastic box in room ( not w/in patient s reach). says she cannot take generic meds provided by hospital, that they may give her an adverse reaction [**last name 19**] problem [**name (ni) 217**] r total knee replacement [**7-6**] assessment: ace wrap to r knee & leg d&i. b dp s & pt s easily palpable. [**initials (namepattern4) **] [**last name (namepattern4) **] intact but no [**male first name (un) **] stocking on r due to ace wrap to r leg. b pneumo boots in place. hemovac/jp kept @ half compression & drained sanguinous drainage. tmax 99.1 po. started dilaudid pca (.25/10/1.5 mg) @ [**2153**] for c/o r knee pain unrelieved w/basal rate of 10mg/hr ketamine. action: removed cpm for night @ 2300. kept pillow between knees. kept towel under r ankle to elevate r heel off bed. no pillow under r knee. patient used is x10 q 1 hr while awake. response: patient c/o intolerable hip (&back) pain when turned side to side despite iv ketamine & dilaudid pca plan: kept patient supine overnight. to get patient up to chair today. .h/o obstructive sleep apnea (osa) assessment: rr 12-21 overnight. o2 sats: 95-98% on 2l np[**md number(3) 218**]: clear to auscultation. refused bipap w/hx osa. action: monitored o2 sats overnight closely response: o2 sats as above. plan: check o2 sats q 4 hrs h/o back pain assessment: patient has chronic back pain, which she experienced when not supine. r leg [**md number(3) **] pain more intense. refused bedpan for this reason. wants to get up to commode during day. action: received neurontin 300mg x2 in eve & 20mg flexeril po which she chronically takes. not given lunesta (sleeper she usually takes) in presence of anesthesia earlier in day as well as iv ketamine & dilaudid. also not given darvocette. response: lights out by 2315. fell asleep in 15min. plan: continue to position patient as she tolerates & encourage is, c& db. get oob. .h/o [**last name **] problem hx prolonged qt interval w/possible syncope assessment: qtc =.38 hr: 60 s-70s sr no ectopy bp: 90 s-130 action: avoided all possible causes of prolonged qt interval such as low k, low mg, dehydration, starvation, hypothyroidism ( received levothyroxin pre-op), and all meds that could lead to prolonged qt (meds listed @ end of this note, & obtained from up to date response: qt interval remained wnl. hr as above. plan: avoid all possible causes of prolonged qt interval as above list of meds to avoid in front of med book as well.",1
322,"59 yo s/p r total knee replacement (uncomplicated) admitted from [** 215**] for monitoring of resp status (hx osa & angioedema following igg administration a year ago). pmh/psh: oa severe, chronic urticaria, steroid induced dm, fibromyalgia, allergic rhinitis, obesity s/p gastric bypass, long qt syndrome, osa but refuses to use cpap, hypothyroidism, cystocele, fld-filled paraspinal mass allergies: sulfa, methadone in [**name (ni) 215**] pt put on ketamine gtt ( via pca pump). patient arrived on cpm @ 0-60 degrees to r knee. note: patient takes own meds which are in clear plastic box in room ( not w/in patient s reach). says she cannot take generic meds provided by hospital, that they may give her an adverse reaction [**last name 19**] problem [**name (ni) 217**] r total knee replacement [**7-6**] assessment: ace wrap to r knee & leg d&i. b dp s & pt s easily palpable. [**initials (namepattern4) **] [**last name (namepattern4) **] intact but no [**male first name (un) **] stocking on r due to ace wrap to r leg. b pneumo boots in place. hemovac/jp kept @ half compression & drained sanguinous drainage. tmax 99.1 po. started dilaudid pca (.25/10/1.5 mg) @ [**2153**] for c/o r knee pain unrelieved w/basal rate of 10mg/hr ketamine. action: removed cpm for night @ 2300. kept pillow between knees. kept towel under r ankle to elevate r heel off bed. no pillow under r knee. patient used is x10 q 1 hr while awake. response: patient c/o intolerable hip (&back) pain when turned side to side despite iv ketamine & dilaudid pca plan: kept patient supine overnight. to get patient up to chair today. .h/o obstructive sleep apnea (osa) assessment: rr 12-21 overnight. o2 sats: 95-98% on 2l np[**md number(3) 218**]: clear to auscultation. refused bipap w/hx osa. action: monitored o2 sats overnight closely response: o2 sats as above. plan: check o2 sats q 4 hrs h/o back pain assessment: patient has chronic back pain, which she experienced when not supine. r leg [**md number(3) **] pain more intense. refused bedpan for this reason. wants to get up to commode during day. action: received neurontin 300mg x2 in eve & 20mg flexeril po which she chronically takes. not given lunesta (sleeper she usually takes) in presence of anesthesia earlier in day as well as iv ketamine & dilaudid. also not given darvocette. response: lights out by 2315. fell asleep in 15min. plan: continue to position patient as she tolerates & encourage is, c& db. get oob. .h/o [**last name **] problem hx prolonged qt interval w/possible syncope assessment: qtc =.38 hr: 60 s-70s sr no ectopy bp: 90 s-130 action: avoided all possible causes of prolonged qt interval such as low k, low mg, dehydration, starvation, hypothyroidism ( received levothyroxin pre-op), and all meds that could lead to prolonged qt (meds listed @ end of this note, & obtained from up to date response: qt interval remained wnl. hr as above. plan: avoid all possible causes of prolonged qt interval as above list of meds to avoid in front of med book as well. medications that could lead to prolonged qt interval: anti-arrythmics: quinidine, procainamide, disopyramide, amiodarone, sotalol, dofetilide, ibutilide, azimilide, sematilide anti-microbials: erythromycin, clarithromycin, telithromycin, azithromycin (minor), some fluoroquinolones (levofloxacin, moxifloxacin, sparfloxacin, gatifloxacin). other antimicrobials: spiramycin, chloroquin, halofantrine, mefluquine antihistamines: terfenadine, astemizole psychotropics: thioridazine, phenothiazines, tricyclic or tetracyclic antidepressants, haloperidol & other batyrophenones, selective serotonin reuptake inhibitors, risperidone, methadone other drugs: vasodilators:prenylamine, bepridil, mibefradil diuretics: via electrolyte changes ( hypokalemia, low mg) serotonin antagonist: ketanserin motility drugs: cisapride, domperidol droperidol, ranolazine hiv protease inhibitors, organophosphate insecticides, probucol, cocaine, terodiline, papaverine, chloral hydrate, arsenic trioxide (chemo), cesium chloride, levomethadyl.",
323,"59 yo s/p r total knee replacement (uncomplicated) admitted from [** 215**] for monitoring of resp status (hx osa & angioedema following igg administration a year ago). pmh/psh: oa severe, chronic urticaria, steroid induced dm, fibromyalgia, allergic rhinitis, obesity s/p gastric bypass, long qt syndrome, osa but refuses to use cpap, hypothyroidism, cystocele, fld-filled paraspinal mass allergies: sulfa, methadone in [**name (ni) 215**] pt put on ketamine gtt ( via pca pump). patient arrived on cpm @ 0-60 degrees to r knee. note: patient takes own meds which are in clear plastic box in room ( not w/in patient s reach). says she cannot take generic meds provided by hospital, that they may give her an adverse reaction [**last name 19**] problem [**name (ni) 217**] r total knee replacement [**7-6**] assessment: ace wrap to r knee & leg d&i. b dp s & pt s easily palpable. [**initials (namepattern4) **] [**last name (namepattern4) **] intact but no [**male first name (un) **] stocking on r due to ace wrap to r leg. b pneumo boots in place. hemovac/jp kept @ half compression & drained sanguinous drainage. tmax 99.1 po. started dilaudid pca (.25/10/1.5 mg) @ [**2153**] for c/o r knee pain unrelieved w/basal rate of 10mg/hr ketamine. action: removed cpm for night @ 2300. kept pillow between knees. kept towel under r ankle to elevate r heel off bed. no pillow under r knee. patient used is x10 q 1 hr while awake. response: patient c/o intolerable hip (&back) pain when turned side to side despite iv ketamine & dilaudid pca plan: kept patient supine overnight. to get patient up to chair today. .h/o obstructive sleep apnea (osa) assessment: rr 12-21 overnight. o2 sats: 95-98% on 2l np[**md number(3) 218**]: clear to auscultation. refused cpap/bipap w/hx osa. action: monitored o2 sats overnight closely response: o2 sats as above. plan: check o2 sats q 4 hrs h/o back pain assessment: patient has chronic back pain, which she experienced when not supine. r leg [**md number(3) **] pain more intense. refused bedpan for this reason. wants to get up to commode during day. action: received neurontin 300mg x2 in eve & 20mg flexeril po which she chronically takes. not given lunesta (sleeper she usually takes) in presence of anesthesia earlier in day as well as iv ketamine & dilaudid. also not given darvocette. response: lights out by 2315. fell asleep in 15min. plan: continue to position patient as she tolerates & encourage is, c& db. get oob. .h/o [**last name **] problem hx prolonged qt interval w/possible syncope assessment: qtc =.38 hr: 60 s-70s sr no ectopy bp: 90 s-130 action: avoided all possible causes of prolonged qt interval such as low k, low mg, dehydration, starvation, hypothyroidism ( received levothyroxin pre-op), and all meds that could lead to prolonged qt (meds listed @ end of this note, & obtained from up to date response: qt interval remained wnl. hr as above. plan: avoid all possible causes of prolonged qt interval as above list of meds to avoid in front of med book as well. medications that could lead to prolonged qt interval: anti-arrythmics: quinidine, procainamide, disopyramide, amiodarone, sotalol, dofetilide, ibutilide, azimilide, sematilide anti-microbials: erythromycin, clarithromycin, telithromycin, azithromycin (minor), some fluoroquinolones (levofloxacin, moxifloxacin, sparfloxacin, gatifloxacin). other antimicrobials: spiramycin, chloroquin, halofantrine, mefluquine antihistamines: terfenadine, astemizole psychotropics: thioridazine, phenothiazines, tricyclic or tetracyclic antidepressants, haloperidol & other batyrophenones, selective serotonin reuptake inhibitors, risperidone, methadone other drugs: vasodilators:prenylamine, bepridil, mibefradil diuretics: via electrolyte changes ( hypokalemia, low mg) serotonin antagonist: ketanserin motility drugs: cisapride, domperidol droperidol, ranolazine hiv protease inhibitors, organophosphate insecticides, probucol, cocaine, terodiline, papaverine, chloral hydrate, arsenic trioxide (chemo), cesium chloride, levomethadyl.",1
324,"59 yo s/p r total knee replacement (uncomplicated) admitted from [** 215**] for monitoring of resp status (hx osa & angioedema following igg administration a year ago). pmh/psh: oa severe, chronic urticaria, steroid induced dm, fibromyalgia, allergic rhinitis, obesity s/p gastric bypass, long qt syndrome, osa but refuses to use cpap, hypothyroidism, cystocele, fld-filled paraspinal mass allergies: sulfa, methadone in [**name (ni) 215**] pt put on ketamine gtt ( via pca pump). patient arrived on cpm @ 0-60 degrees to r knee. note: patient takes own meds which are in clear plastic box in room ( not w/in patient s reach). says she cannot take generic meds provided by hospital, that they may give her an adverse reaction. [**last name 19**] problem [**name (ni) 217**] r total knee replacement [**7-6**] assessment: ace wrap to r knee & leg d&i. b dp s & pt s easily palpable. [**initials (namepattern4) **] [**last name (namepattern4) **] intact but no [**male first name (un) **] stocking on r due to ace wrap to r leg. b pneumo boots in place. hemovac/jp kept @ half compression & drained 170cc sanguinous drainage from 1900-0000. tmax 99.1 po. started dilaudid pca (.25/10/1.5 mg) @ [**2153**] for c/o r knee pain unrelieved w/basal rate of 10mg/hr ketamine. action: removed cpm for night @ 2300. kept pillow between knees. kept towel under r ankle to elevate r heel off bed. no pillow under r knee. patient used is x10 q 1 hr while awake. response: patient c/o intolerable hip (&back) pain when turned side to side despite iv ketamine & dilaudid pca plan: kept patient supine overnight. .h/o obstructive sleep apnea (osa) assessment: rr 12-21 overnight. o2 sats: 95-98% on 2l np[**md number(3) 218**]: clear to auscultation. refused cpap/bipap w/hx osa. action: patient required continuous o2 sat monitoring in presence of ketamine & dilaudid for pain as well as osa response: o2 sats as above. plan: transfer patient to floor in am [**7-7**] .h/o back pain assessment: patient has chronic back pain, which she experienced when not supine. r leg [**month/year (2) **] pain more intense. refused bedpan for this reason. action: received neurontin 300mg x2 in eve & 20mg flexeril po which she chronically takes. not given lunesta (sleeper she usually takes) in presence of anesthesia earlier in day as well as iv ketamine & dilaudid. also not given darvocette. response: lights out by 2315. fell asleep in 15min. plan: continue to position patient as she tolerates & encourage is, c& db. .h/o [**last name **] problem hx prolonged qt interval w/possible syncope assessment: qtc =.38 hr: 60 s-70s sr no ectopy bp: 90 s-130 action: avoided all possible causes of prolonged qt interval such as low k, low mg, dehydration, starvation, hypothyroidism ( received levothyroxin pre-op), and all meds that could lead to prolonged qt (meds listed @ end of this note, & obtained from up to date response: qt interval remained wnl. hr as above. plan: avoid all possible causes of prolonged qt interval as above list of meds to avoid in front of med book as well. medications that could lead to prolonged qt interval: anti-arrythmics: quinidine, procainamide, disopyramide, amiodarone, sotalol, dofetilide, ibutilide, azimilide, sematilide anti-microbials: erythromycin, clarithromycin, telithromycin, azithromycin (minor), some fluoroquinolones (levofloxacin, moxifloxacin, sparfloxacin, gatifloxacin). other antimicrobials: spiramycin, chloroquin, halofantrine, mefluquine antihistamines: terfenadine, astemizole psychotropics: thioridazine, phenothiazines, tricyclic or tetracyclic antidepressants, haloperidol & other batyrophenones, selective serotonin reuptake inhibitors, risperidone, methadone other drugs: vasodilators:prenylamine, bepridil, mibefradil diuretics: via electrolyte changes ( hypokalemia, low mg) serotonin antagonist: ketanserin motility drugs: cisapride, domperidol droperidol, ranolazine hiv protease inhibitors, organophosphate insecticides, probucol, cocaine, terodiline, papaverine, chloral hydrate, arsenic trioxide (chemo), cesium chloride, levomethadyl.",
325,"59 yo s/p r total knee replacement (uncomplicated) admitted from [** 215**] for monitoring of resp status (hx osa & angioedema following igg administration a year ago). pmh/psh: oa severe, chronic urticaria, steroid induced dm, fibromyalgia, allergic rhinitis, obesity s/p gastric bypass, long qt syndrome, osa but refuses to use cpap, hypothyroidism, cystocele, fld-filled paraspinal mass allergies: sulfa, methadone in [**name (ni) 215**] pt put on ketamine gtt ( via pca pump). patient arrived on cpm @ 0-60 degrees to r knee. note: patient takes own meds which are in clear plastic box in room ( not w/in patient s reach). says she cannot take generic meds provided by hospital, that they may give her an adverse reaction. also, unbleached bed linen used on bed. [**last name 19**] problem [**name (ni) 217**] r total knee replacement [**7-6**] assessment: ace wrap to r knee & leg d&i. b dp s & pt s easily palpable. [**initials (namepattern4) **] [**last name (namepattern4) **] intact but no [**male first name (un) **] stocking on r due to ace wrap to r leg. b pneumo boots in place. hemovac/jp kept @ half compression & drained sanguinous drainage. tmax 99.1 po. started dilaudid pca (.25/10/1.5 mg) @ [**2153**] for c/o r knee pain unrelieved w/basal rate of 10mg/hr ketamine. pain was rated 6 for most of the night. patient was relatively comfortable @ that level. occasionally bumped up to 8. only went up to 10 during blood draw in am when both ketamine & diladid were off for a short time to draw blood. action: removed cpm for night @ 2300. restarted cpm @ 0500. kept pillow between knees. kept towel under r ankle to elevate r heel off bed. no pillow under r knee. patient used is x10 q 1 hr while awake. ice packs applied to r knee all night (refilled q 4 hrs ). response: patient c/o intolerable hip (&back) pain when turned side to side despite iv ketamine & dilaudid pca plan: kept patient supine overnight. to get patient up to chair today. .h/o obstructive sleep apnea (osa) assessment: rr 12-21 overnight. o2 sats: 95-98% on 2l np[**md number(3) 218**]: clear to auscultation. refused cpap/bipap w/hx osa. action: monitored o2 sats overnight closely response: o2 sats as above. plan: check o2 sats q 4 hrs h/o back pain assessment: patient has chronic back pain, which she experienced when not supine. r leg [**md number(3) **] pain more intense. refused bedpan for this reason. wants to get up to commode during day. action: received neurontin 300mg x2 in eve & 20mg flexeril po which she chronically takes. not given lunesta (sleeper she usually takes) in presence of anesthesia earlier in day as well as iv ketamine & dilaudid. also not given darvocette. response: lights out by 2315. fell asleep in 15min. slept until awoken @ 0400. plan: continue to position patient as she tolerates & encourage is, c& db. get oob. .h/o [**last name **] problem hx prolonged qt interval w/possible syncope assessment: qtc =.38 hr: 60 s-70s sr no ectopy bp: 90 s-130 action: avoided all possible causes of prolonged qt interval such as low k, low mg, dehydration, starvation, hypothyroidism ( received levothyroxin pre-op), and all meds that could lead to prolonged qt (meds listed @ end of this note, & obtained from up to date response: qt interval remained wnl. hr as above. plan: avoid all possible causes of prolonged qt interval as above list of meds to avoid in front of med book as well. medications that could lead to prolonged qt interval: anti-arrythmics: quinidine, procainamide, disopyramide, amiodarone, sotalol, dofetilide, ibutilide, azimilide, sematilide anti-microbials: erythromycin, clarithromycin, telithromycin, azithromycin (minor), some fluoroquinolones (levofloxacin, moxifloxacin, sparfloxacin, gatifloxacin). other antimicrobials: spiramycin, chloroquin, halofantrine, mefluquine antihistamines: terfenadine, astemizole psychotropics: thioridazine, phenothiazines, tricyclic or tetracyclic antidepressants, haloperidol & other batyrophenones, selective serotonin reuptake inhibitors, risperidone, methadone other drugs: vasodilators:prenylamine, bepridil, mibefradil diuretics: via electrolyte changes ( hypokalemia, low mg) serotonin antagonist: ketanserin motility drugs: cisapride, domperidol droperidol, ranolazine hiv protease inhibitors, organophosphate insecticides, probucol, cocaine, terodiline, papaverine, chloral hydrate, arsenic trioxide (chemo), cesium chloride, levomethadyl.",1
326,"chief complaint: admitted for airway observation s/p tkr 24 hour events: history obtained from [**hospital 31**] medical records allergies: history obtained from [**hospital 31**] medical recordssulfa (sulfonamides) unknown; methadone seizures; last dose of antibiotics: cefazolin - [**2162-7-7**] 04:00 am infusions: ketamine - 10 mg/hour other icu medications: other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2162-7-7**] 07:47 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.3 c (99.1 tcurrent: 36.7 c (98 hr: 73 (58 - 84) bpm bp: 96/46(57) {92/23(47) - 134/90(95)} mmhg rr: 14 (12 - 23) insp/min spo2: 96% heart rhythm: sr (sinus rhythm) height: 64 inch total in: 4,616 ml 657 ml po: 835 ml 420 ml tf: ivf: 3,781 ml 237 ml blood products: total out: 1,442 ml 790 ml urine: 600 ml 660 ml ng: stool: drains: 180 ml 130 ml balance: 3,174 ml -133 ml respiratory support o2 delivery device: nasal cannula spo2: 96% abg: ///22/ physical examination peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) skin: not assessed neurologic: responds to: not assessed, movement: not assessed, tone: not assessed labs / radiology 152 k/ul 9.0 g/dl 100 mg/dl 0.5 mg/dl 22 meq/l 3.2 meq/l 6 mg/dl 109 meq/l 140 meq/l 27.1 % 7.1 k/ul [image002.jpg] [**2162-7-7**] 03:25 am wbc 7.1 hct 27.1 plt 152 cr 0.5 glucose 100 other labs: ca++:6.8 mg/dl, mg++:1.4 mg/dl, po4:3.3 mg/dl assessment and plan 59 yo f with complicated medical history including hypogammaglobulinemia, osa and morbid obesity and a history of angioedema in the past, s/p uneventful right tkr, here for observation of airway status post-operatively. #. airway: patient is breathing comfortably, without stridor. she feels her breathing is at its baseline. will observe the patient overnight for evidence of airway compromise. . #. s/p right tkr: patient with minimal pain. will continue ketamine gtt per surgical team. dilaudid pca if pain becomes worse. cpm will continue overnight. further management deferred to surgical team. . #. osa: patient has a history of ""severe"" osa, but has consistently refused bipap. we will monitor her carefully overnight especially in the post-operative setting with ketamine on board. . #. copd: continue albuterol, singulair, prednisone. . #. hypogammaglobulinemia: received ivig this morning prior to surgery. no further acute issues for now. . #. niddm: continue metformin, insulin sliding scale. diabetic diet. . #. hypothyroidism: continue levothyroxine. . #. prolonged qt: per patient, known for 3 years since taking methadone to which she had an adverse reaction. monitor on telemetry. avoid medications that will prolong the qt further. . #. gerd: omeprazole. . #. fen: diabetic diet. replete lytes prn. . icu care nutrition: glycemic control: lines: 22 gauge - [**2162-7-6**] 05:00 pm 18 gauge - [**2162-7-6**] 05:00 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: full code disposition:",1
327,demographics day of mechanical ventilation: 0 ideal body weight: 61.2 none ideal tidal volume: 244.8 / 367.2 / 489.6 ml/kg airway airway placement data known difficult intubation: no tube type tracheostomy tube: type: perc trach manufacturer: portex size: 8.0mm cuff management: cuff pressure: 20 cmh2o lung sounds rll lung sounds: diminished rul lung sounds: clear lul lung sounds: clear lll lung sounds: diminished comments: secretions sputum color / consistency: / none : ventilation assessment level of breathing assistance: unassisted spontaneous breathing visual assessment of breathing pattern: pt remains on t/c during night and tolerated well. neb alb/atr given x1 with no adverse reactions. 02 sats 96%. plan is to continue on t/c. vent pulled. plan next 24-48 hours: remain on t/c,0
328,"chief complaint: s/p total knee replacement, airway observation hpi: this is a 59 yo f with a past medical history significant for osa, morbid obesity, copd and hypogammaglobulinemia who was admitted today for right total knee replacement. this morning, she received a dose of ivig, did well intra and postoperatively, however, she is admitted to the [**hospital unit name 10**] for observation of her airway postoperatively given her history of angioedema in [**10-22**]. this was of unclear etiology but thought due to medications and did not require intubation. . in the [**date range 215**], her vitals were t 97.6, bp 120/70, hr 50's, rr 10-15 satting in the mid 90's on 2l by nc. on arrival to the [**hospital unit name 10**], she is on a ketamine gtt, she is alert and communicative and complains of very mild pain in her right knee. patient admitted from: [**hospital1 1**] or / [**hospital1 215**] history obtained from patient allergies: sulfa (sulfonamides) unknown; methadone seizures; last dose of antibiotics: infusions: ketamine - 10 mg/hour other icu medications: other medications: singulair 10 amlodipine 5 propanolol 80 cyclobenzaprine 20 qhs lunesta 2 qhs hydroxyzine 25 1-2q4-6prn darvocet prn potassium chloride 10 meq daily bumex 1 simvastatin 20 zyrtec prn prednisone 20 zantac prn cellcept [**pager number 216**] metformin 500 neurontin 300 levothyroxine 88 rhinocort prn prilosec 20 amerge 2.5 prn for headache proventil past medical history: family history: social history: hypogammaglobulinemia and chronic severe urticaria treated with ivig infusions osa morbid obesity- bmi of 43 niddm copd autoimmune hypothyroidism s/p gastric bypass prolonged qt interval and possibly with syncopal episodes migraines history of angioedema - autoimmune urticaria/angioedema syndrome gerd fibromyalgia hypercholesterolemia h/o recurrent pneumonias djd back father died of ""blocked arteries. no family history of sudden death. occupation: unemployed drugs: none tobacco: none alcohol: none other: review of systems: complains of minimal pain in right knee. otherwise, denies sob, chest pain, palpitations, abdominal pain, difficulty swallowing. otherwise ros is negative in detail flowsheet data as of [**2162-7-6**] 06:02 pm vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.6 c (97.8 tcurrent: 36.6 c (97.8 hr: 67 (67 - 67) bpm bp: 134/82(95) {134/82(95) - 134/82(95)} mmhg rr: 20 (20 - 23) insp/min spo2: 100% heart rhythm: sr (sinus rhythm) height: 64 inch total in: 15 ml po: tf: ivf: 15 ml blood products: total out: 0 ml 115 ml urine: 45 ml ng: stool: drains: 70 ml balance: 0 ml -100 ml respiratory o2 delivery device: nasal cannula 2l spo2: 100% physical examination general: obese 59 yo f, alert, nad heent: eomi, perrl, anicteric. op clear, mm dry, edentulous. unable to assess jvp given habitus. chest: distant heart sounds, rrr no m/r/g lungs: small lung volumes, clear to auscultation anteriorly/laterally abd: obese, soft, nt/nd +bs ext: no e/c/c, wwp skin: warm and dry, no rashes neuro: cn ii-xii in tact bilaterally, sensation to lt in tact bilaterally, motor [**4-19**] on upper and lle, can wiggle toes on rle. rle in cpm. labs / radiology [image002.jpg] cxr: none. . [**2162-6-24**]: tte: the left atrium is normal in size. 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 number of aortic valve leaflets cannot be determined. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. there is an anterior space which most likely represents a fat pad. impression: normal left and right ventricular function. normal valvular function. . ekg: pending assessment and plan 59 yo f with complicated medical history including hypogammaglobulinemia, osa and morbid obesity and a history of angioedema in the past, s/p uneventful right tkr, here for observation of airway status post-operatively. #. airway: patient is breathing comfortably, without stridor. she feels her breathing is at its baseline. will observe the patient overnight for evidence of airway compromise. . #. s/p right tkr: patient with minimal pain. will continue ketamine gtt per surgical team. dilaudid pca if pain becomes worse. cpm will continue overnight. further management deferred to surgical team. . #. osa: patient has a history of ""severe"" osa, but has consistently refused bipap. we will monitor her carefully overnight especially in the post-operative setting with ketamine on board. . #. copd: continue albuterol, singulair, prednisone. . #. hypogammaglobulinemia: received ivig this morning prior to surgery. no further acute issues for now. . #. niddm: continue metformin, insulin sliding scale. diabetic diet. . #. hypothyroidism: continue levothyroxine. . #. prolonged qt: per patient, known for 3 years since taking methadone to which she had an adverse reaction. monitor on telemetry. avoid medications that will prolong the qt further. . #. gerd: omeprazole. . #. fen: diabetic diet. replete lytes prn. . icu care nutrition: glycemic control: metformin, insulin gtt lines: 2 piv 22 gauge - [**2162-7-6**] 05:00 pm 18 gauge - [**2162-7-6**] 05:00 pm prophylaxis: dvt: lovenox stress ulcer: omeprazole (on at home) vap: n/a comments: communication: comments: with patient code status: full code disposition: [**hospital unit name 10**] overnight, will reevaluate in am for ?floor on ortho service",1
329,"title: respiratory care: rec d pt on psv 3/5/40%. bs are coarse bilaterally and suctioning for thick copious bloody plugs/secretions. mdi administered as ordered alb with no adverse reactions. am abg 738/40/76/22 rsbi= 36 plan: screening for rehab, although now pt presents with fever. t/c trials as tolerates.",0
330,"demographics ideal body weight: 49.9 none ideal tidal volume: 199.6 / 299.4 / 399.2 ml/kg airway pt on ffv (niv) lung sounds rll lung sounds: diminished rul lung sounds: rhonchi lul lung sounds: diminished lll lung sounds: diminished secretions sputum color / consistency: / sputum source/amount: / comments: ventilation assessment non-invasive ventilation assessment: tolerated well, mask induced abrasions; comments: some breakdown on nose plan next 24-48 hours: plan to wean niv as tolerated, pt being followed by hospice reason for continuing current ventilatory support: underlying illness not resolved tx: xopenex nebs administered with no adverse reactions.",0
331,"chief complaint: fever, nausea, vomitting hpi: 65-year-old female with a long history of interstitial cystitis s/p cystectomy and ileal neo-bladder p/w urosepsis from osh. pt was having abd pain, n/v for past 3 days. the pain is in lower abd and radiating to the back. it was [**10-8**] in severity. also c/o diarrhea last night. hence she went to osh. she had a ct abd there and was read as appendicitis w/ ? of perf and abscess. she was seen by [**doctor first name **] there but requested a xfer to [**hospital1 1**]. . in the ed, initial vs were: t99.4(tm 101.4) p74 bp90/48 (lowest 85/41) r o2 sat 97/ra. the osh ct scan was reviwed by rads attg here. there is no e/o of appendicitis (also pt has a h/o appy). there is e/o l hydrouerter which is a common finding in pt w/ neobladder. patient recd 4l ivf given that she was hypotensive. she was given levaquin and zosyn in osh ed and recd vanco in ed here. . on arrival to the icu, the pain was [**4-8**]. she was mildly nauseous. she denied any chills, was feeling thirsty. no cp/sob/dizzy/palps. patient admitted from: [**hospital1 1**] er history obtained from patient allergies: pcns: convulsion; last dose of antibiotics: vanc in er at [**hospital1 1**] zosyn/levoflox at osh er infusions: other icu medications: morphine sulfate - [**2100-12-23**] 10:30 pm other medications: trimethoprim 100 qd past medical history: family history: social history: -interstitial cystitis s/p cyctectomy and ileal neo-bladder -s/p appy -s/p ccy no cad, dm, htn occupation: drugs: no tobacco: no alcohol: occasional other: lives w/ husband review of systems: constitutional: fever ear, nose, throat: dry mouth gastrointestinal: abdominal pain, nausea, emesis, diarrhea genitourinary: no(t) dysuria pain: [**3-2**] mild pain location: lower abd flowsheet data as of [**2100-12-23**] 10:58 pm vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 38 c (100.4 tcurrent: 38 c (100.4 hr: 73 (73 - 74) bpm bp: 104/47(60) {89/41(53) - 104/47(60)} mmhg rr: 17 (15 - 17) insp/min spo2: 96% heart rhythm: sr (sinus rhythm) total in: 6,000 ml po: tf: ivf: 1,000 ml blood products: total out: 0 ml 800 ml urine: 200 ml ng: stool: drains: balance: 0 ml 5,200 ml respiratory o2 delivery device: nasal cannula 4l spo2: 96% physical examination general appearance: well nourished, no acute distress eyes / conjunctiva: perrl head, ears, nose, throat: normocephalic lymphatic: no(t) cervical adenopathy cardiovascular: (s1: normal), (s2: normal), no(t) s3, no(t) s4, no(t) rub, (murmur: no(t) systolic, no(t) diastolic) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: present), (left dp pulse: present) respiratory / chest: (expansion: symmetric), (breath sounds: crackles : bibasilar) abdominal: soft, bowel sounds present, cva tenderness + b/l, no hsm extremities: right: absent, left: absent, no(t) cyanosis, no(t) clubbing skin: no(t) rash: neurologic: attentive, follows simple commands, oriented (to): aao x 3. cn ii-xii intact, strength normal and equal b/l, no sensory deficit, no cerebellar signs labs / radiology 214 110 0.8 12 23 107 3.8 138 32.1 11.9 [image002.jpg] fluid analysis / other labs: ua:>50 wbcs, many bact imaging: cxr: blunting of l cp angle. e/o fluid overload + microbiology: pnd ecg: sr, <1mm std in v3-v6 which is new.low voltage assessment and plan 65 year-old female with a long history of interstitial cystitis s/p cystectomy and ileal neo-bladder p/w urosepsis . #urosepsis: pt with h/o interstitial cystitis s/p cystectomy and ileal neo-bladder. has had multiple utis since this surgery in 07. has been on prophylactic abx without much benefit. -cont vanc, zosyn till cx and sensitivities are back. pt reports allergy to pcns but received zosyn at osh without any adverse reaction. -f/u bld cx, ucx from here as well as from osh -will hold off on more ivf as cxr shows fluid overload and pt with new o2 requirement. -consider urology c/s -monitor physical exam for cva tenderness and overall worsening of urosepsis . #hypoxia: pt not c/o sob but dropping her satts to 90% on ra. cxr shows vol overload and small l pleural effusion -hold off on further ivf. pt's bp at baseline -o2 by nc -once infection under control, consider diuresis if pt does not autodiurese . # fen: replete electrolytes, regular diet . # prophylaxis: subcutaneous heparin . # access: 18 g and 20 g . # code: full . # communication: patient and husband [**telephone/fax (1) 3072**] . # disposition: icu icu care nutrition: reg diet, replete lytes prn glycemic control: blood sugar well controlled lines: 18 gauge - [**2100-12-23**] 09:17 pm 20 gauge - [**2100-12-23**] 09:18 pm prophylaxis: dvt: sq uf heparin stress ulcer: vap: comments: communication: comments: code status: full code disposition: icu",0
332,"chief complaint: fever, nausea, vomitting hpi: 65-year-old female with a long history of interstitial cystitis s/p cystectomy and ileal neo-bladder p/w urosepsis from osh. pt was having abd pain, n/v for past 3 days. the pain is in lower abd and radiating to the back. it was [**10-8**] in severity. also c/o diarrhea last night. hence she went to osh. she had a ct abd there and was read as appendicitis w/ ? of perf and abscess. she was seen by [**doctor first name **] there but requested a xfer to [**hospital1 1**]. . in the ed, initial vs were: t99.4(tm 101.4) p74 bp90/48 (lowest 85/41) r o2 sat 97/ra. the osh ct scan was reviwed by rads attg here. there is no e/o of appendicitis (also pt has a h/o appy). there is e/o l hydrouerter which is a common finding in pt w/ neobladder. patient recd 4l ivf given that she was hypotensive. she was given levaquin and zosyn in osh ed and recd vanco in ed here. . on arrival to the icu, the pain was [**4-8**]. she was mildly nauseous. she denied any chills, was feeling thirsty. no cp/sob/dizzy/palps. patient admitted from: [**hospital1 1**] er history obtained from patient allergies: pcns: convulsion; last dose of antibiotics: vanc in er at [**hospital1 1**] zosyn/levoflox at osh er infusions: other icu medications: morphine sulfate - [**2100-12-23**] 10:30 pm other medications: trimethoprim 100 qd past medical history: family history: social history: -interstitial cystitis s/p cyctectomy and ileal neo-bladder -s/p appy -s/p ccy no cad, dm, htn occupation: drugs: no tobacco: no alcohol: occasional other: lives w/ husband review of systems: constitutional: fever ear, nose, throat: dry mouth gastrointestinal: abdominal pain, nausea, emesis, diarrhea genitourinary: no(t) dysuria pain: [**3-2**] mild pain location: lower abd flowsheet data as of [**2100-12-23**] 10:58 pm vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 38 c (100.4 tcurrent: 38 c (100.4 hr: 73 (73 - 74) bpm bp: 104/47(60) {89/41(53) - 104/47(60)} mmhg rr: 17 (15 - 17) insp/min spo2: 96% heart rhythm: sr (sinus rhythm) total in: 6,000 ml po: tf: ivf: 1,000 ml blood products: total out: 0 ml 800 ml urine: 200 ml ng: stool: drains: balance: 0 ml 5,200 ml respiratory o2 delivery device: nasal cannula 4l spo2: 96% physical examination general appearance: well nourished, no acute distress eyes / conjunctiva: perrl head, ears, nose, throat: normocephalic lymphatic: no(t) cervical adenopathy cardiovascular: (s1: normal), (s2: normal), no(t) s3, no(t) s4, no(t) rub, (murmur: no(t) systolic, no(t) diastolic) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: present), (left dp pulse: present) respiratory / chest: (expansion: symmetric), (breath sounds: crackles : bibasilar) abdominal: soft, bowel sounds present, cva tenderness + b/l, no hsm extremities: right: absent, left: absent, no(t) cyanosis, no(t) clubbing skin: no(t) rash: neurologic: attentive, follows simple commands, oriented (to): aao x 3. cn ii-xii intact, strength normal and equal b/l, no sensory deficit, no cerebellar signs labs / radiology 214 110 0.8 12 23 107 3.8 138 32.1 11.9 [image002.jpg] fluid analysis / other labs: ua:>50 wbcs, many bact imaging: cxr: blunting of l cp angle. e/o fluid overload + microbiology: pnd ecg: sr, <1mm std in v3-v6 which is new.low voltage assessment and plan 65 year-old female with a long history of interstitial cystitis s/p cystectomy and ileal neo-bladder p/w urosepsis . #urosepsis: pt with h/o interstitial cystitis s/p cystectomy and ileal neo-bladder. has had multiple utis since this surgery in 07. has been on prophylactic abx without much benefit. -cont vanc, zosyn till cx and sensitivities are back. pt reports allergy to pcns but received zosyn at osh without any adverse reaction. -f/u bld cx, ucx from here as well as from osh -will hold off on more ivf as cxr shows fluid overload and pt with new o2 requirement. -consider urology c/s -monitor physical exam for cva tenderness and overall worsening of urosepsis . #hypoxia: pt not c/o sob but dropping her satts to 90% on ra. cxr shows vol overload and small l pleural effusion -hold off on further ivf. pt's bp at baseline -o2 by nc -once infection under control, consider diuresis if pt does not autodiurese . # fen: replete electrolytes, regular diet . # prophylaxis: subcutaneous heparin . # access: 18 g and 20 g . # code: full . # communication: patient and husband [**telephone/fax (1) 3072**] . # disposition: icu icu care nutrition: reg diet, replete lytes prn glycemic control: blood sugar well controlled lines: 18 gauge - [**2100-12-23**] 09:17 pm 20 gauge - [**2100-12-23**] 09:18 pm prophylaxis: dvt: sq uf heparin stress ulcer: vap: comments: communication: comments: code status: full code disposition: icu ------ protected section ------ attending addendum: i saw and examined the patient, and was physically present with the icu resident for key portions of the services provided. i agree with his / her note above, including assessment and plan. key points: uti and/or pyelonephritis with sepsis, hypotensive s/p fluid resuscitation. appears well on exam with mild cva tenderness on exam but ct not c/w pyelo. will reexamine in am to determine whether cva tenderness persists. hypoxemic with cxr c/w pleural effusion on left and pulmonary vascular congestion, bilateral crackles. when bp stabilizes (ie tomorrow) can consider gentle diuresis from her considerable volume resuscitation. icu critically ill with sepsis 33 minutes. ------ protected section addendum entered by:[**name (ni) 101**] [**last name (namepattern1) 65**], md on:[**2100-12-23**] 23:15 ------",0
333,"chief complaint: fever, nausea, vomitting hpi: 65-year-old female with a long history of interstitial cystitis s/p cystectomy and ileal neo-bladder p/w urosepsis from osh. pt was having abd pain, n/v for past 3 days. the pain is in lower abd and radiating to the back. it was [**10-8**] in severity. also c/o diarrhea last night. hence she went to osh. she had a ct abd there and was read as appendicitis w/ ? of perf and abscess. she was seen by [**doctor first name **] there but requested a xfer to [**hospital1 1**]. . in the ed, initial vs were: t99.4(tm 101.4) p74 bp90/48 (lowest 85/41) r o2 sat 97/ra. the osh ct scan was reviwed by rads attg here. there is no e/o of appendicitis (also pt has a h/o appy). there is e/o l hydrouerter which is a common finding in pt w/ neobladder. patient recd 4l ivf given that she was hypotensive. she was given levaquin and zosyn in osh ed and recd vanco in ed here. . on arrival to the icu, the pain was [**4-8**]. she was mildly nauseous. she denied any chills, was feeling thirsty. no cp/sob/dizzy/palps. patient admitted from: [**hospital1 1**] er history obtained from patient allergies: pcns: convulsion; last dose of antibiotics: vanc in er at [**hospital1 1**] zosyn/levoflox at osh er infusions: other icu medications: morphine sulfate - [**2100-12-23**] 10:30 pm other medications: trimethoprim 100 qd past medical history: family history: social history: -interstitial cystitis s/p cyctectomy and ileal neo-bladder -s/p appy -s/p ccy no cad, dm, htn occupation: drugs: no tobacco: no alcohol: occasional other: lives w/ husband review of systems: constitutional: fever ear, nose, throat: dry mouth gastrointestinal: abdominal pain, nausea, emesis, diarrhea genitourinary: no(t) dysuria pain: [**3-2**] mild pain location: lower abd flowsheet data as of [**2100-12-23**] 10:58 pm vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 38 c (100.4 tcurrent: 38 c (100.4 hr: 73 (73 - 74) bpm bp: 104/47(60) {89/41(53) - 104/47(60)} mmhg rr: 17 (15 - 17) insp/min spo2: 96% heart rhythm: sr (sinus rhythm) total in: 6,000 ml po: tf: ivf: 1,000 ml blood products: total out: 0 ml 800 ml urine: 200 ml ng: stool: drains: balance: 0 ml 5,200 ml respiratory o2 delivery device: nasal cannula 4l spo2: 96% physical examination general appearance: well nourished, no acute distress eyes / conjunctiva: perrl head, ears, nose, throat: normocephalic lymphatic: no(t) cervical adenopathy cardiovascular: (s1: normal), (s2: normal), no(t) s3, no(t) s4, no(t) rub, (murmur: no(t) systolic, no(t) diastolic) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: present), (left dp pulse: present) respiratory / chest: (expansion: symmetric), (breath sounds: crackles : bibasilar) abdominal: soft, bowel sounds present, cva tenderness + b/l, no hsm extremities: right: absent, left: absent, no(t) cyanosis, no(t) clubbing skin: no(t) rash: neurologic: attentive, follows simple commands, oriented (to): aao x 3. cn ii-xii intact, strength normal and equal b/l, no sensory deficit, no cerebellar signs labs / radiology 214 110 0.8 12 23 107 3.8 138 32.1 11.9 [image002.jpg] fluid analysis / other labs: ua:>50 wbcs, many bact imaging: cxr: blunting of l cp angle. e/o fluid overload + microbiology: pnd ecg: sr, <1mm std in v3-v6 which is new.low voltage assessment and plan 65 year-old female with a long history of interstitial cystitis s/p cystectomy and ileal neo-bladder p/w urosepsis . #urosepsis: pt with h/o interstitial cystitis s/p cystectomy and ileal neo-bladder. has had multiple utis since this surgery in 07. has been on prophylactic abx without much benefit. -cont vanc, zosyn till cx and sensitivities are back. pt reports allergy to pcns but received zosyn at osh without any adverse reaction. -f/u bld cx, ucx from here as well as from osh -will hold off on more ivf as cxr shows fluid overload and pt with new o2 requirement. -consider urology c/s -monitor physical exam for cva tenderness and overall worsening of urosepsis . #hypoxia: pt not c/o sob but dropping her satts to 90% on ra. cxr shows vol overload and small l pleural effusion -hold off on further ivf. pt's bp at baseline -o2 by nc -once infection under control, consider diuresis if pt does not autodiurese . # fen: replete electrolytes, regular diet . # prophylaxis: subcutaneous heparin . # access: 18 g and 20 g . # code: full . # communication: patient and husband [**telephone/fax (1) 3072**] . # disposition: icu icu care nutrition: reg diet, replete lytes prn glycemic control: blood sugar well controlled lines: 18 gauge - [**2100-12-23**] 09:17 pm 20 gauge - [**2100-12-23**] 09:18 pm prophylaxis: dvt: sq uf heparin stress ulcer: vap: comments: communication: comments: code status: full code disposition: icu ------ protected section ------ attending addendum: i saw and examined the patient, and was physically present with the icu resident for key portions of the services provided. i agree with his / her note above, including assessment and plan. key points: uti and/or pyelonephritis with sepsis, hypotensive s/p fluid resuscitation. appears well on exam with mild cva tenderness on exam but ct not c/w pyelo. will reexamine in am to determine whether cva tenderness persists. hypoxemic with cxr c/w pleural effusion on left and pulmonary vascular congestion, bilateral crackles. when bp stabilizes (ie tomorrow) can consider gentle diuresis from her considerable volume resuscitation. icu critically ill with sepsis 33 minutes. ------ protected section addendum entered by:[**name (ni) 101**] [**last name (namepattern1) 65**], md on:[**2100-12-23**] 23:15 ------ ------ protected section addendum entered by:[**name (ni) 101**] [**last name (namepattern1) 65**], md on:[**2100-12-24**] 01:09 ------",0
334,"chief complaint: 24 hour events: hd stable history obtained from patient allergies: history obtained from patientall drug allergies previously recorded have been deleted convulsion; last dose of antibiotics: piperacillin/tazobactam (zosyn) - [**2100-12-24**] 04:31 am infusions: other icu medications: morphine sulfate - [**2100-12-23**] 10:30 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: constitutional: no(t) fatigue, no(t) fever genitourinary: no(t) dysuria, foley flowsheet data as of [**2100-12-24**] 10:55 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 38 c (100.4 tcurrent: 35.4 c (95.8 hr: 82 (56 - 82) bpm bp: 100/47(58) {82/38(50) - 111/50(60)} mmhg rr: 19 (10 - 19) insp/min spo2: 97% heart rhythm: sr (sinus rhythm) height: 66 inch total in: 6,000 ml 705 ml po: tf: ivf: 1,000 ml 705 ml blood products: total out: 900 ml 620 ml urine: 300 ml 620 ml ng: stool: drains: balance: 5,100 ml 85 ml respiratory support o2 delivery device: none spo2: 97% abg: ///17/ physical examination general appearance: well nourished, no acute distress eyes / conjunctiva: perrl head, ears, nose, throat: normocephalic lymphatic: no(t) cervical adenopathy cardiovascular: (s1: normal), (s2: normal), (murmur: no(t) systolic, no(t) diastolic) peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: present), (left dp pulse: present) respiratory / chest: (breath sounds: clear : ) abdominal: soft, non-tender extremities: right: absent, left: absent, no(t) cyanosis, no(t) clubbing skin: not assessed neurologic: responds to: not assessed, movement: not assessed, tone: not assessed labs / radiology 177 k/ul 8.9 g/dl 64 mg/dl 0.6 mg/dl 17 meq/l 3.5 meq/l 9 mg/dl 119 meq/l 141 meq/l 26.6 % 12.4 k/ul [image002.jpg] [**2100-12-24**] 03:56 am wbc 12.4 hct 26.6 plt 177 cr 0.6 glucose 64 assessment and plan 65 year-old female with a long history of interstitial cystitis s/p cystectomy and ileal neo-bladder p/w urosepsis . #urosepsis: pt with h/o interstitial cystitis s/p cystectomy and ileal neo-bladder. has had multiple utis since this surgery in 07. has been on prophylactic abx without much benefit. -cont zosyn till cx and sensitivities are back. pt reports allergy to pcns but received zosyn at osh without any adverse reaction. -f/u bld cx, ucx from here as well as from osh -will hold off on more ivf as cxr shows fluid overload and pt with new o2 requirement. -consider urology c/s . #hypoxia: pt not c/o sob but dropping her satts to 90% on ra. cxr shows vol overload and small l pleural effusion -hold off on further ivf. pt's bp at baseline -o2 by nc -once infection under control, consider diuresis if pt does not autodiurese . # fen: replete electrolytes, regular diet . # prophylaxis: subcutaneous heparin . # access: 18 g and 20 g . # code: full . # communication: patient and husband [**telephone/fax (1) 3072**] . # disposition: icu icu care nutrition: glycemic control: blood sugar well controlled lines: 20 gauge - [**2100-12-23**] 09:00 pm 18 gauge - [**2100-12-23**] 09:17 pm prophylaxis: dvt: sq uf heparin stress ulcer: vap: comments: communication: comments: code status: full code disposition:",0
335,"76 yo female with significant pmh. admitted [**2-1**] with raf rxed medically & subsequently converted to nsr on rate control meds. echo showed sever m&tr-workup initiated for m&tvr. [**2-4**] started on disopyramide (norpace) long acting. [**2-6**] increased ventricular ectopy which progressed into torsades (known adverse reaction to norpace)-pt hemodynamically stable-rxed with magnesium sulfate with concersion to nsr. transferred to ccu for further management. upon admission multiple episodes of torades all responding to iv magnesium & 1x lidocaine bolus. [**2045**] onset torsades-multiple episodes resulting in code blue cpr, meds, & defibrilated into nsr. intubated for airway management. lined-aline & mlc. family present & aware of events resulting in code blue ventricular tachycardia, sustained (torsades). assessment: sedated with fent/versed gtts-responsive to noxious stimuli/not following commands @ present. gd abg/sats-minimal secretions. cxr dose. without further episodes of torsades. started on levophed for borderline hypotension. attempted low dose lopressor (resulting hr low 60 s). isuprel gtt started. heparin gtt continues. ogt placed. adeq uo. afebrile. action: on low dose fent/versed for comfort. vap protocol followed. levophed titrated to sbp >100. isuprel gtt titrated to hr >80<90. continued magnesium iv 2gm q4hrs. family updated by team (pts son primary care physician). lytes cked & replaced as indicated. response: without further episodes of torsades. sbp & hr within set goals. vent settings adjusted to abgs. plan: contin present management. support pt/family as indicated. will need cardiac cath-m&tvr workup & breast biopsy-known breast mass when stable.",1
336,"title: overnight intensivist admission [**age over 90 **] y/o nh resident with fever, lactate acidosis, ""tremors"". see medical student and housestaff note for details. briefly, nh resident with dementia here with above. recent history notable for nasal congestion and rhinorrhea. in ed, temp of 104, r fem line placed d/t inability to get access. neuro consulted for tremor - felt more likely rigors vs adverse reaction to namenda (recent new med). lactate to 4.4, decreased after 2l ivf. cxr wet read as new l infiltrate. pmhx: alzhemiers, bph, hemorrhoidectomy nkda meds: namenda and donepezil, citalopram social: [**hospital1 4641**], ex-podiatrist t99, 121/50, p87, r16, 98% ra perrl, eomi no sinus tenderness, minimal discharge no jvd, neck supple rrr s1 s2 no m lung cta b/l abd distended with increased tone, soft +bs cool extremities no edema r fem line in place tone sl increased b/l throughout (vs resistance) 5/5 strength grossly, limited exam labs: 11.6 / 31.5 (down from 12.5 / 36.4), 84.8n inr 1.2 7.49/31/146 chem-7: 135, 4.0, 24, 21/1.2 gluc 140. lactate 4.4 -> 1.6 ck 26 u/a neg. blood cx pending. cxr as above. prior opacities c/w pleural plaques. a/p: [**age over 90 **] y/o nh resident with fever to 104, lactic acidosis, tremors vs rigors. febrile syndrome of unclear etiology in absence of symptoms, only report of ?tremor vs rigor in setting of fevers. likely sepsis, but unclear source. report of infiltrate on cxr though difficult to see by my eye - certainly underwhelming, in lack of cough / sx / exam findings. abd distended - check lfts/[**doctor first name **]/lip, cdiff. empiric broad coverage with vanc zosyn ok for now. with tremor vs rigor as sole suggestive finding for meningitis vs other source - seems unlikely, will consider but for now defer pending results of further labs / cultures. lactate sole evidence of severity of sepsis, no other evidence of [**last name (un) 4642**] dysfunction; bolus prn for bp/ u/o. for ?tremor, ?increased tone: for now hold psych meds. follow exam, f/u with neuro in am. sq heparin access: groin line, piv -- likely d/c groin in am full code",1
337,"title: overnight intensivist admission [**age over 90 **] y/o nh resident with fever, lactate acidosis, ""tremors"". see medical student and housestaff note for details. briefly, nh resident with dementia here with above. recent history notable for nasal congestion and rhinorrhea. in ed, temp of 104, r fem line placed d/t inability to get access. neuro consulted for tremor - felt more likely rigors vs adverse reaction to namenda (recent new med). lactate to 4.4, decreased after 2l ivf. cxr wet read as new l infiltrate, sent to [**hospital unit name 10**]. here, extensive ros including dyspnea, cough, headache, photophobia, negative. feels fine and has no complaints. pmhx: alzhemiers, bph, hemorrhoidectomy nkda meds: namenda and donepezil, citalopram social: [**hospital1 4641**], ex-podiatrist t99, 121/50, p87, r16, 98% [**hospital **] hospital and the 10^th unsure of month. perrl, eomi no sinus tenderness, minimal discharge no jvd, neck supple rrr s1 s2 no m lung cta b/l abd distended with increased tone, soft +bs cool extremities no edema r fem line in place tone sl increased b/l throughout (vs resistance) 5/5 strength grossly, limited exam. no clonus labs: 11.6 / 31.5 (down from 12.5 / 36.4), 84.8n inr 1.2 7.49/31/146 chem-7: 135, 4.0, 24, 21/1.2 gluc 140. lactate 4.4 -> 1.6 ck 26 u/a neg. blood cx pending. cxr as above. prior opacities c/w pleural plaques. a/p: [**age over 90 **] y/o nh resident with fever to 104, lactic acidosis, tremors vs rigors. febrile syndrome of unclear etiology in absence of symptoms (though in setting of advanced dementia), only report of generalized tremor vs rigor in setting of fevers. likely sepsis, but unclear source. report of infiltrate on cxr though difficult to see by my eye - certainly underwhelming, in lack of cough / sx / exam findings. abd distended - check lfts/[**doctor first name **]/lip, cdiff. empiric broad coverage with vanc zosyn ok for now. with tremor vs rigor as sole suggestive finding for meningitis vs other source - seems unlikely, will consider but for now defer pending results of further labs / cultures. lactate sole evidence of severity of sepsis, no other evidence of organ dysfunction; bolus prn for bp/ u/o. dementia; generalized tremor, ?increased tone: will hold psych meds. follow exam, f/u with neuro in am. ppx: sq heparin access: groin line, piv -- likely able to d/c groin line in am full code",1
338,"title: overnight intensivist admission [**age over 90 **] y/o nh resident with fever, lactate acidosis, ""tremors"". see medical student and housestaff note for details. briefly, nh resident with dementia here with above. recent history notable for nasal congestion and rhinorrhea. in ed, temp of 104, r fem line placed d/t inability to get access. neuro consulted for tremor - felt more likely rigors vs adverse reaction to namenda (recent new med). lactate to 4.4, decreased after 2l ivf. cxr wet read as new l infiltrate, sent to [**hospital unit name 10**]. here, extensive ros including dyspnea, cough, headache, photophobia, negative. feels fine and has no complaints. pmhx: alzhemiers, bph, hemorrhoidectomy nkda meds: namenda and donepezil, citalopram social: [**hospital1 4641**], ex-podiatrist t99, 121/50, p87, r16, 98% [**hospital **] hospital and the 10^th unsure of month. perrl, eomi no sinus tenderness, minimal discharge no jvd, neck supple rrr s1 s2 no m lung cta b/l abd distended with increased tone, soft +bs cool extremities no edema r fem line in place tone sl increased b/l throughout (vs resistance) 5/5 strength grossly, limited exam. no clonus labs: 11.6 / 31.5 (down from 12.5 / 36.4), 84.8n inr 1.2 7.49/31/146 chem-7: 135, 4.0, 24, 21/1.2 gluc 140. lactate 4.4 -> 1.6 ck 26 u/a neg. blood cx pending. cxr as above. prior opacities c/w pleural plaques. a/p: [**age over 90 **] y/o nh resident with fever to 104, lactic acidosis, tremors vs rigors. febrile syndrome of unclear etiology in absence of symptoms (though in setting of advanced dementia), only report of generalized tremor vs rigor in setting of fevers. likely sepsis, but unclear source. report of infiltrate on cxr though difficult to see by my eye - certainly underwhelming, in lack of cough / sx / exam findings. abd distended - check lfts/[**doctor first name **]/lip, cdiff. empiric broad coverage with vanc zosyn ok for now. with tremor vs rigor as sole suggestive finding for meningitis vs other source - seems unlikely, will consider but for now defer pending results of further labs / cultures. lactate sole evidence of severity of sepsis, no other evidence of organ dysfunction; bolus prn for bp/ u/o. dementia; generalized tremor, ?increased tone: will hold psych meds. follow exam, f/u with neuro in am. ppx: sq heparin access: groin line, piv -- likely able to d/c groin line in am full code",1
339,demographics ideal body weight: 86.2 none ideal tidal volume: 344.8 / 517.2 / 689.6 ml/kg lung sounds rll lung sounds: diminished rul lung sounds: clear lul lung sounds: clear lll lung sounds: diminished comments: ventilation assessment level of breathing assistance: unassisted spontaneous breathing visual assessment of breathing pattern: assessment of breathing comfort: no claim of dyspnea) plan next 24-48 hours: nebulizers of xopenex/atrovent given as ordered with no adverse reactions. continue to follow. pt on 3 lpm n/c,0
340,"hx aml s/p chemotherapy, found to have recurrent disease. he was recently admitted for midam (aracytin and mitoxantrone) chemotherapy and discharged two days prior to this admission. developed abd pain in the evening of his prior discharge. he had two more episodes of liquid stool on the evening prior to admission. he did not report abdominal pain at that time. he was admitted to the bmt service after arriving to the clinic for routine labs, getting a platelet transfusion for thrombocytopenia, and then having a fever to 102.5 despite acetaminophen pre-medication. he was started on aztreonam, vancomycin, and metronidazole on admission. blood cultures drawn on [**6-20**] showed two species of gram-negative rods, still being speciated and with sensitivities pending. [**6-22**] abdomen increasingly tympanitic and distended through the day after having a ct abdomen/pelvis yesterday ([**6-21**]) showing possible duodenitis. he had some epigastric pain and tenderness to palpation. c/o of some abdominal pain. lft s were worsening considerably with starkly rising lfts through the day. his lactate was rising. platelets remained very low despite several transfusions of platelets. neutrophil count of 0. abd ct scan negative for perforation. trans to [**hospital unit name 10**] for further management. [**6-24**] lfts worsening,. intubated for increased wob, o2 requirement, encephalopathy. bacteremia assessment: wbc 0.1. no adverse reaction s/p meropenim desensitization overnight. t-max 100.8po. action: meropenin 1000 mg q8 started. cont on acyclovir, vanco. surveillance bc x2 done. response: tol meropenem 1000 mg. plan: cont antibiotics. obtain vanco level prior to [**2192**] dose this eve. follow temp, wbc, culture data pancytopenia assessment: plts 13, pt 22.4, crit 23.9. small amt blood with oral care action: transfused one unit prbc s, bag plts & plts. vit k 5mg po x1 response: hemodynamically stable plan: transfuse to goal of 50k for plts, ffp until pt <20, follow labs, assess for bleeding respiratory failure, acute (not ards/[**doctor last name 2**]) assessment: remains intubated & sedated. abg stable. minimal tan to brown secretions action: no vent changes, oral care q4hrs. hob +/or reverse t-[**doctor last name **] to decrease thoracic pressure response: stable on above vent settings plan: follow abg, resp exam abd exam. keep hob elevated hepatitis other assessment: lft s remain elevated but beginning to trend down. abd firm, distended. hypoactive bs. npo. ngt to lcws for period of time this eve. minimally responsive on fentanyl 200 mcg hr & versed 2mg hr gtts. action: completing acetylcysteine infusion. fentanyl decreased to 175 mcg & versed 1mg. response: lft s trending down. abd essentially unchanged. occas will [**doctor last name 115**] off vent , otherwise no [**doctor last name **] ge in ms [**name13 (stitle) 149**]: follow lft s, abd exam, npo. stool culture with next bm pt & pt s mother in to visit most of the shift. updated frequently throughout the shift by this rn. [**doctor first name 1072**] saganov, social worker will follow up with family in am",0
341,"title: overnight intensivist admission 60 y/o all recurrent, prolonged hospital course here with 3^rd [**hospital unit name 10**] admission for wide complex tachycardia. please see resident note for details. briefly, 60 y/o admitted for all recurrence [**2-27**] and received donor lymphocyte infusion, hypercvad, intrathecal ara-c and methotrexate. she was admitted to the [**hospital unit name 10**] [**4-13**] with declining mental status complicated by pea arrest, underlying cause suspected omaya shunt infection and infected sdh. mental status improved and returned to the floor. she returned to the [**hospital unit name 10**] for hypoxemic respiratory failure on [**4-25**], complicated by hypotension and pea arrest, felt to be in cardiogenic shock (echo ef 20%, down from prior) treated with norepi and dobutamine and diuresed, eventually extubated [**4-30**]. icu course also notable for hyponatremia, receiving hypertonic saline. transferred back to the bmt service on [**4-30**]. this pm noted to be in wide complex tachycardia, with respiratory distress and chest pain. a code blue was called. her initial vs were p150 and bp 120/80. 150mg of amio and started on a drip with immediate response; hr came down to 100 s, where it has remained since. of note, while she was not hypotensive during the code, she had transiently low bp just prior to transfer and was given 1l of ns. on arrival to the icu, she was anxious, and given ativan. currently she denies any pain or dyspnea. allergies: include antibiotic allergies to pcn, sulfas, numerous other adverse reactions listed pmhx: all as above s/p non-related donor sct in [**2169**], juvenile ra, psvt and pat, h/o laryngeal spasm, irritable bowel, avascular necrosis of hip, lue clot, hypothyroidism, anal stricture, h/o poor access with no access available in the ue and l groin line placed by ir on [**4-12**]. t98 bp 104/68 rr32 94% on 4l. sleepy but arousable. alopecia, surgical scar on head lue 4+ edema, rue 2+ rrr 2/6 sm lungs cta ant / lat b/l abd soft, ostomy 2+ le edema, anasarca mae weakly to command l groin line labs: wbc 10.9 / 34 / 99 (stable) 126 / 4.7 / 88 / 16 / 9 / 0.7 / 238 (during code): 126/3.8/90/20 prior ca 8.1 mg 1.8 po4 3.4 ck 54 mb 13 trop 0.28 alt 75 / ast 33 alk phos 192 ldh 429 (stable) 7.35/18/124 bicarb 10 lactate 8.5 (~1h p arrival) cxr: b/l r>l effusion, r mid / retrocardiac opacity, mild vascular engorgement to me c/w edema. ekgs reviewed: baseline nsr, nl axis. tachycardia qrs 130, rate 150, lbbb pattern, r present in v6. post-amio: sinus, ivcd qrs ~112, lbbb pattern a/p: 60 y/o all, cardiomyopathy, here with new wide complex tachycardia, lactic acidosis. wide complex tachycardia: vt vs svt with aberrancy will review with cardiology. underlying cause known cm from chemo, trigger by infection, acid-base disturbance, electrolyte disturbance, ischemia. for now, continue amiodarone; cycle enzymes, follow ekg, and consider asa / beta blocker, consider re-echo. lactic acidosis: measured soon after code / vt; however, concerning that bicarb had been dropping earlier in day as well. follow closely if remains elevated, will need further eval; notably on previous admit in cardiogenic shock, requiring pressors; ideally would also check a central venous sat, but unable (see below) vre bacteremia: continue linezolid hyponatremia: na stable, water restrict ppx: sq heparin access: complex issue, last line placement was change over wire of l groin line done by ir. does not draw back, though infuses. no other access available r groin and b/l neck and upper extremities all previously attempted, per report. code: full, confirmed.",1
342,"41 year old male with melanoma metastasized to liver, bones, skin, heart, lungs, and brain, on hospice at home but now a full code. pt recently admitted to osh for pna per wife and started having increased sob over last 2 to 3 weeks with some fevers. in ed temp 101.8, ct of chest negative for pe but (+) for rrl pna, new mets to brain also noted. per wife pt had adverse reaction to combination of ativan and dialudid in ed becoming unresponsive. significant events since micu admission: pt electively intubated late in the afternoon of [**7-15**] with adverse events- becoming hypoxic due to ett malfunction and going into v-tach with a pulse, pt successfully cardioverted and started on pressors for a short period of time which were turned of at midnight of [**7-16**]. a febrile blood transfusion also occurred [**7-15**] after 1.25 units prbc was transfused for hct 19 today, pt had exploratory bronchoscopy with a bal showing active right side bleeding and an obstructive tumor in left lower lobe, ip plans to take pt to or and pt is being transferred to [**hospital ward name **] for further management dyspnea (shortness of breath) assessment: received pt intubated on a/c 40%/500/18/5 breathing at a rate of 20-27 but appearing comfortable. intermittent coughing spells, suctioning copious amounts of frank red blood requiring lavage. sp02 94-100%. lung rhonchus throughout with exp/insp wheezing. fentanyl gtt @ 75 mcg/hr and versed gtt @ 4 mg/hr running, requires 1 mg versed and 25 mcg fentanyl boluses q2-3 hours. follows commands consistently, denying pain. tmax 99.8 orally this morning action: pulmonary toileting, iv abx for previously suspected pna, sedation to comfort, uneventful bronch today, tylenol prn response: vent settings remain the same with sp02 95-100%, requiring frequent lavage suction. temp responded to tylenol, now 99.2 orally plan: pulmonary toileting, continue with iv abx for now, follow micro data from bronch, one set of bc pending. hypotension (not shock) assessment: pt off neo gtt since midnight with abp 95-115/60-80 s (femoral a-line initially in with variable waveform, but nbp correlated to above bp st low 100 s. condom cath in place as pt is difficult to catheterize, urine concentrated with uo 30-100. abdomen soft with good bowel sounds, ogt in place. action: 500 ns bolus given for sbp 88, radial a-line placed response: bp responded to fluid, now with sbp 115-130 plan: monitor bp, ivf and vasopressors as needed. monitor uo- needs to be seen by urology. tf s need to be started anemia, acute, secondary to blood loss (hemorrhage, bleeding) assessment: as previously stated, pt actively bleeding from right lung and suctioning copious amount of blood from ett, hct 19.7 action: given additional 2 units prbc early this am despite prior reaction, premedicated with tylenol and benadryl response: repeat hct 25.7 plan: pending 1600 hct, transfuse prn and premedicate with benadryl and tylenol",1
343,"41 year old male with melanoma metastasized to liver, bones, skin, heart, lungs, and brain, on hospice at home but now a full code. pt recently admitted to osh for pna per wife and started having increased sob over last 2 to 3 weeks with some fevers. in ed temp 101.8, ct of chest negative for pe but (+) for rrl pna, new mets to brain also noted. per wife pt had adverse reaction to combination of ativan and dialudid in ed becoming unresponsive. significant events since micu admission: pt electively intubated late in the afternoon of [**7-15**] with adverse events- becoming hypoxic due to ett malfunction and going into v-tach with a pulse, pt successfully cardioverted and started on pressors for a short period of time, turned of midnight of [**7-16**]. a febrile blood transfusion also occurred [**7-15**] after 1.25 units prbc today, pt had exploratory bronchoscopy with a bal showing active right side bleeding and an obstructive tumor in left lower lobe, ip plans to take pt to or and pt is being transferred to [**hospital ward name **] for further management dyspnea (shortness of breath) assessment: received pt intubated on a/c 40%/500/18/5 breathing at a rate of 20-27 but appearing comfortable. intermittent coughing spells, suctioning copious amounts of frank red blood requiring lavage. sp02 94-100%. lung rhonchus throughout with exp/insp wheezing. fentanyl gtt @ 50-75 mcg/hr and versed gtt @ 4 mg/hr running, requires 1 mg versed and 25 mcg fentanyl boluses q2-3 hours. follows commands consistently, denying pain action: pulmonary toileting, iv abx for previously suspected pna, sedation to comfort, uneventful bronch today response: vent settings remain the same with sp02 95-100%, requiring frequent lavage suction plan: pulmonary toileting, continue with iv abx for now, follow micro data from bronch, one set of bc pending hypotension (not shock) assessment: pt off neo gtt since midnight with abp 95-115/60-80 s, st low 100 condom cath in place as pt is difficult to catheterize, urine concentrated with uo 30-100. abdomen soft with good bowel sounds, ogt in place. action: 500 ns bolus given for sbp 88 response: bp responded to fluid, now with sbp 100-110 plan: monitor bp, ivf and vasopressors as needed. monitor uo- needs to be seen by urology. tf s need to be started anemia, acute, secondary to blood loss (hemorrhage, bleeding) assessment: as previously stated, pt actively bleeding from right lung and suctioning copious amount of blood from ett, hct 19.7 action: given additional 2 units prbc early this am despite prior reaction, premedicated with tylenol and benadryl response: repeat hct 25.7 plan: pending 1600 hct, transfuse for hct <24. premedicated with benadryl and tylenol",1
344,"41 year old male with melanoma metastasized to liver, bones, skin, heart, lungs, and brain, on hospice at home but now a full code. pt recently admitted to osh for pna per wife and started having increased sob over last 2 to 3 weeks with some fevers. in ed temp 101.8, ct of chest negative for pe but (+) for rrl pna, new mets to brain also noted. per wife pt had adverse reaction to combination of ativan and dialudid in ed becoming unresponsive. significant events since micu admission: pt electively intubated late in the afternoon of [**7-15**] with adverse events- becoming hypoxic due to ett malfunction and going into v-tach with a pulse, pt successfully cardioverted and started on pressors for a short period of time which were turned of at midnight of [**7-16**]. a febrile blood transfusion also occurred [**7-15**] after 1.25 units prbc was transfused for hct 19 today, pt had exploratory bronchoscopy with a bal showing active right side bleeding and an obstructive tumor in left lower lobe, ip plans to take pt to or and pt is being transferred to [**hospital ward name **] for further management dyspnea (shortness of breath) assessment: received pt intubated on a/c 40%/500/18/5 breathing at a rate of 20-27 but appearing comfortable. intermittent coughing spells, suctioning copious amounts of frank red blood requiring lavage. sp02 94-100%. lung rhonchus throughout with exp/insp wheezing. fentanyl gtt @ 75 mcg/hr and versed gtt @ 4 mg/hr running, requires 1 mg versed and 25 mcg fentanyl boluses q2-3 hours. follows commands consistently, denying pain. tmax 99.8 orally this morning action: pulmonary toileting, iv abx for previously suspected pna, sedation to comfort, uneventful bronch today, tylenol prn response: vent settings remain the same with sp02 95-100%, requiring frequent lavage suction. temp responded to tylenol, now 99.2 orally plan: pulmonary toileting, continue with iv abx for now, follow micro data from bronch, one set of bc pending. hypotension (not shock) assessment: pt off neo gtt since midnight with abp 95-115/60-80 s (femoral a-line initially in with variable waveform, but nbp correlated to above bp st low 100 s. condom cath in place as pt is difficult to catheterize, urine concentrated with uo 30-100. abdomen soft with good bowel sounds, ogt in place. action: 500 ns bolus given for sbp 88, radial a-line placed response: bp responded to fluid, now with sbp 115-130 plan: monitor bp, ivf and vasopressors as needed. monitor uo- needs to be seen by urology. tf s need to be started anemia, acute, secondary to blood loss (hemorrhage, bleeding) assessment: as previously stated, pt actively bleeding from right lung and suctioning copious amount of blood from ett, hct 19.7 action: given additional 2 units prbc early this am despite prior reaction, premedicated with tylenol and benadryl response: repeat hct 25.7 plan: pending 1600 hct, transfuse prn and premedicate with benadryl and tylenol",1
345,"41 year old male with melanoma metastasized to liver, bones, skin, heart, lungs, and brain, on hospice at home but now a full code. pt recently admitted to osh for pna per wife and started having increased sob over last 2 to 3 weeks with some fevers. in ed temp 101.8, ct of chest negative for pe but (+) for rrl pna, new mets to brain also noted. per wife pt had adverse reaction to combination of ativan and dialudid in ed becoming unresponsive. significant events since micu admission: pt electively intubated late in the afternoon of [**7-15**] with adverse events- becoming hypoxic due to ett malfunction and going into v-tach with a pulse, pt successfully cardioverted and started on pressors for a short period of time, turned of midnight of [**7-16**]. a febrile blood transfusion also occurred [**7-15**] after 1.25 units prbc today, pt had exploratory bronchoscopy with a bal showing active right side bleeding and an obstructive tumor in left lower lobe, ip plans to take pt to or and pt is being transferred to [**hospital ward name **] for further management dyspnea (shortness of breath) assessment: received pt intubated on a/c 40%/500/18/5 breathing at a rate of 20-27 but appearing comfortable. intermittent coughing spells, suctioning copious amounts of frank red blood requiring lavage. sp02 94-100%. lung rhonchus throughout with exp/insp wheezing. fentanyl gtt @ 50-75 mcg/hr and versed gtt @ 4 mg/hr running, requires 1 mg versed and 25 mcg fentanyl boluses q2-3 hours. follows commands consistently, denying pain action: pulmonary toileting, iv abx for previously suspected pna, sedation to comfort, uneventful bronch today response: vent settings remain the same with sp02 95-100%, requiring frequent lavage suction plan: pulmonary toileting, continue with iv abx for now, follow micro data from bronch, one set of bc pending hypotension (not shock) assessment: pt off neo gtt since midnight with abp 95-115/60-80 s (femoral a-line initially in with variable waveform, but nbp correlated to above bp st low 100 s. condom cath in place as pt is difficult to catheterize, urine concentrated with uo 30-100. abdomen soft with good bowel sounds, ogt in place. action: 500 ns bolus given for sbp 88, radial a-line placed response: bp responded to fluid, now with sbp 115-130 plan: monitor bp, ivf and vasopressors as needed. monitor uo- needs to be seen by urology. tf s need to be started anemia, acute, secondary to blood loss (hemorrhage, bleeding) assessment: as previously stated, pt actively bleeding from right lung and suctioning copious amount of blood from ett, hct 19.7 action: given additional 2 units prbc early this am despite prior reaction, premedicated with tylenol and benadryl response: repeat hct 25.7 plan: pending 1600 hct, transfuse for hct <24. premedicated with benadryl and tylenol",1
346,"41 year old male with melanoma metastasized to liver, bones, skin, heart, lungs, and brain, on hospice at home but now a full code. pt recently admitted to osh for pna per wife and started having increased sob over last 2 to 3 weeks with some fevers. in ed temp 101.8, ct of chest negative for pe but (+) for rrl pna, new mets to brain also noted. per wife pt had adverse reaction to combination of ativan and dialudid in ed becoming unresponsive. significant events since micu admission: pt electively intubated late in the afternoon of [**7-15**] with adverse events- becoming hypoxic due to ett malfunction and going into v-tach with a pulse, pt successfully cardioverted and started on pressors for a short period of time, turned of midnight of [**7-16**]. today, pt had exploratory bronchoscopy with a bal showing active right side bleeding and an obstructive tumor in left lower lobe, ip plans to take pt to or and pt is being transferred to [**hospital ward name **] for further management dyspnea (shortness of breath) assessment: received pt intubated on a/c 40%/500/18/5 breathing at a rate of 20-27 but appearing comfortable. intermittent coughing spells, suctioning copious amounts of frank red blood requiring lavage. sp02 94-100%. lung rhonchus throughout with exp/insp wheezing. fentanyl gtt @ 50-75 mcg/hr and versed gtt @ 4 mg/hr running, requires 1 mg versed and 25 mcg fentanyl boluses q2-3 hours. follows commands action: pulmonary toileting, iv abx for previously suspected pna, sedation to comfort, uneventful bronch today response: plan: hypotension (not shock) assessment: action: response: plan: anemia, acute, secondary to blood loss (hemorrhage, bleeding) assessment: action: response: plan:",1
347,"41 year old male with melanoma metastasized to liver, bones, skin, heart, lungs, and brain, on hospice at home but now a full code. pt recently admitted to osh for pna per wife and started having increased sob over last 2 to 3 weeks with some fevers. in ed temp 101.8, ct of chest negative for pe but (+) for rrl pna, new mets to brain also noted. per wife pt had adverse reaction to combination of ativan and dialudid in ed becoming unresponsive. significant events since micu admission: pt electively intubated late in the afternoon of [**7-15**] with adverse events- becoming hypoxic due to ett malfunction and going into v-tach with a pulse, pt successfully cardioverted and started on pressors for a short period of time which were turned of at midnight of [**7-16**]. a febrile blood transfusion also occurred [**7-15**] after 1.25 units prbc was transfused for hct 19 today, pt had exploratory bronchoscopy with a bal showing active right side bleeding and an obstructive tumor in left lower lobe, ip plans to take pt to or and pt is being transferred to [**hospital ward name **] for further management dyspnea (shortness of breath) assessment: received pt intubated on a/c 40%/500/18/5 breathing at a rate of 20-27 but appearing comfortable. intermittent coughing spells, suctioning copious amounts of frank red blood requiring lavage. sp02 94-100%. lung rhonchus throughout with exp/insp wheezing. fentanyl gtt @ 75 mcg/hr and versed gtt @ 4 mg/hr running, requires 1 mg versed and 25 mcg fentanyl boluses q2-3 hours. follows commands consistently, denying pain. tmax 98.8 orally this morning action: pulmonary toileting, iv abx for previously suspected pna, sedation to comfort, uneventful bronch today, tylenol prn, fentanyl inc to 125mcq for comfort. response: vent settings remain the same with sp02 95-100%, requiring frequent lavage suction. temp 98.8 orally plan: pulmonary toileting, continue with iv abx for now, follow micro data from bronch, one set of bc pending. hypotension (not shock) assessment: abp 95-115/60-80 sst low 100 s. condom cath in place as pt is difficult to catheterize, urine concentrated with uo 30-100. abdomen soft with good bowel sounds, ogt in place. action: 1 liter lr bolus given for sbp 88, radial a-line response: bp responded to fluid, now with sbp 115-130 plan: monitor bp, ivf and vasopressors as needed. monitor uo- needs to be seen by urology. tf s started and then stopped at midnight for procedure in the am. anemia, acute, secondary to blood loss (hemorrhage, bleeding) assessment: as previously stated, pt actively bleeding from right lung and suctioning copious amount of blood from ett, hct 25. action: cont to monitor freq hct s for loss of blood. response: repeat hct 25.7 plan: transfuse prn and premedicate with benadryl and tylenol",1
348,"41 year old male with melanoma metastasized to liver, bones, skin, heart, lungs, and brain, on hospice at home but now a full code. pt recently admitted to osh for pna per wife and started having increased sob over last 2 to 3 weeks with some fevers. in ed temp 101.8, ct of chest negative for pe but (+) for rrl pna, new mets to brain also noted. per wife pt had adverse reaction to combination of ativan and dialudid in ed becoming unresponsive. significant events since micu admission: pt electively intubated late in the afternoon of [**7-15**] with adverse events- becoming hypoxic due to ett malfunction and going into v-tach with a pulse, pt successfully cardioverted and started on pressors for a short period of time, turned of midnight of [**7-16**]. today, pt had exploratory bronchoscopy with a bal. dyspnea (shortness of breath) assessment: action: response: plan: hypotension (not shock) assessment: action: response: plan: anemia, acute, secondary to blood loss (hemorrhage, bleeding) assessment: action: response: plan:",1
349,"41 year old male with melanoma metastasized to liver, bones, skin, heart, lungs, and brain, on hospice at home but now a full code. pt recently admitted to osh for pna per wife and started having increased sob over last 2 to 3 weeks with some fevers. in ed temp 101.8, ct of chest negative for pe but (+) for rrl pna, new mets to brain also noted. per wife pt had adverse reaction to combination of ativan and dialudid in ed becoming unresponsive. significant events since micu admission: pt electively intubated late in the afternoon of [**7-15**] with adverse events- becoming hypoxic due to ett malfunction and going into v-tach with a pulse, pt successfully cardioverted and started on pressors for a short period of time which were turned of at midnight of [**7-16**]. a febrile blood transfusion also occurred [**7-15**] after 1.25 units prbc was transfused for hct 19 today, pt had exploratory bronchoscopy with a bal showing active right side bleeding and an obstructive tumor in left lower lobe, ip plans to take pt to or and pt is being transferred to [**hospital ward name **] for further management dyspnea (shortness of breath) assessment: received pt intubated on a/c 40%/500/18/5 breathing at a rate of 20-27 but appearing comfortable. intermittent coughing spells, suctioning copious amounts of frank red blood requiring lavage. sp02 94-100%. lung rhonchus throughout with exp/insp wheezing. fentanyl gtt @ 75 mcg/hr and versed gtt @ 4 mg/hr running, requires 1 mg versed and 25 mcg fentanyl boluses q2-3 hours. follows commands consistently, denying pain. tmax 98.8 orally this morning action: pulmonary toileting, iv abx for previously suspected pna, sedation to comfort, uneventful bronch today, tylenol prn, fentanyl inc to 125mcq for comfort. response: vent settings remain the same with sp02 95-100%, requiring frequent lavage suction. temp 98.8 orally plan: pulmonary toileting, continue with iv abx for now, follow micro data from bronch, one set of bc pending. hypotension (not shock) assessment: abp 95-115/60-80 sst low 100 s. condom cath in place as pt is difficult to catheterize, urine concentrated with uo 30-100. abdomen soft with good bowel sounds, ogt in place. action: 1 liter lr bolus given for sbp 88, radial a-line response: bp responded to fluid, now with sbp 115-130 plan: monitor bp, ivf and vasopressors as needed. monitor uo- needs to be seen by urology. tf s started and then stopped at midnight for procedure in the am. anemia, acute, secondary to blood loss (hemorrhage, bleeding) assessment: as previously stated, pt actively bleeding from right lung and suctioning copious amount of blood from ett, hct 25. action: cont to monitor freq hct s for loss of blood. response: repeat hct 25.7 plan: transfuse prn and premedicate with benadryl and tylenol",1
350,"57yo f with 6yr h/o ulcerative colitis, admitted [**2137-7-21**] with abdominal pain and bloody bowel movements. on [**7-29**] underwent total colectomy and end ileostomy; post-op course c/b pe resulting in initiation of iv heparin. on [**8-7**] pt w/ falling hct and increasing abd pain returned to or after ct revealed large intrapelvic hematoma which was evacuated and additional portion of ileum was removed. . impaired skin integrity assessment: pt c/o itching , mild diffuse rash noted slightly changed in severity since last reported action: md aware, no culprit revealed ,12.5 iv benadryl given response: pt admits to itching now diminished plan: cont to assess skin for outbreaks, investigate possible culprits, benadryl for symptoms pulmonary embolism (pe), acute assessment: on heprin gtt at sub therapeutic level action: md aware , changed dosing scale , increased to 500 units/hr response: no adverse reaction plan: re check ptt @ 0900 dose as per ss increasing in 100 units increments",0
351,"demographics day of mechanical ventilation: 7 ideal body weight: 78 none ideal tidal volume: [**telephone/fax (3) 280**] ml/kg airway airway placement data known difficult intubation: unknown tube type ett: position: 24 cm at lip route: oral type: standard size: 7.5mm cuff management: vol/press: cuff pressure: 26 cmh2o lung sounds rll lung sounds: diminished rul lung sounds: rhonchi lul lung sounds: rhonchi lll lung sounds: diminished secretions sputum color / consistency: blood tinged / thick sputum source/amount: suctioned / small comments: mdi's of alb/atr given as ordered, no adverse reactions ventilation assessment level of breathing assistance: intermittent invasive ventilation visual assessment of breathing pattern: normal quiet breathing; comments: abg 7.40/45/81 with rsbi=33. assessment of breathing comfort: no claim of dyspnea) invasive ventilation assessment: trigger work assessment: triggering synchronously plan next 24-48 hours: continue with daily rsbi tests & sbt's as tolerated; comments: plan to wean to sbt then possible extubation? reason for continuing current ventilatory support: cannot protect airway, cannot manage secretions, underlying illness not resolved",0
352,"title: chief complaint: 24 hour events: - echo: small residual pericardial effusion, effusive-constrictive physiology - thoracics aware - fluid gram stain negative, prelim cx no growth, no afb - started on colchicine (cope trial) - pcn allergy confirmed rash on legs, switched aztreonam to cefepime, will monitor for adverse reaction - dfa negative x2, sent third sample; can also wait for culture from first swab (ready in 48h) - fluid cx: gpc in clusters pain with deep inspiration. allergies: penicillins- leg rash last dose of antibiotics: aztreonam - [**2137-1-19**] 07:00 am vancomycin - [**2137-1-19**] 10:00 pm levofloxacin - [**2137-1-19**] 10:00 pm cefipime - [**2137-1-20**] 04:00 am infusions: other icu medications: morphine sulfate - [**2137-1-19**] 11:30 am heparin sodium (prophylaxis) - [**2137-1-19**] 10:00 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2137-1-20**] 07:41 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.6 c (99.6 tcurrent: 36.3 c (97.3 hr: 97 (85 - 113) bpm bp: 141/89(100) {112/51(67) - 149/93(103)} mmhg rr: 23 (15 - 39) insp/min spo2: 95% heart rhythm: sr (sinus rhythm) height: 67 inch total in: 4,975 ml 127 ml po: 2,950 ml tf: ivf: 2,025 ml 127 ml blood products: total out: 5,250 ml 550 ml urine: 5,250 ml 550 ml ng: stool: drains: balance: -275 ml -423 ml respiratory support o2 delivery device: nasal cannula spo2: 95% abg: ///26/ physical examination general: wdwn tachypneic taking shallow breaths speaking in broken sentences. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 10 cm. +kussmaul s sign cardiac: pmi located in 5th intercostal space, midclavicular line. tachycardic, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. pericardial drain pulled, dressing c/d/i. lungs: no chest wall deformities, scoliosis or kyphosis. decreased breath sounds at bases. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominal bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ labs / radiology 476 k/ul 10.1 g/dl 108 mg/dl 0.9 mg/dl 26 meq/l 4.5 meq/l 11 mg/dl 104 meq/l 141 meq/l 30.6 % 6.1 k/ul [image002.jpg] [**2137-1-18**] 08:45 pm [**2137-1-19**] 05:17 am [**2137-1-20**] 06:28 am wbc 8.4 8.6 6.1 hct 27.0 28.4 30.6 plt [**telephone/fax (3) 9849**] cr 0.9 0.8 0.9 tropt <0.01 glucose 171 103 108 other labs: pt / ptt / inr:15.0/30.9/1.3, ck / ckmb / troponin-t:65//<0.01, alt / ast:242/124, alk phos / t bili:163/0.5, differential-neuts:77.7 %, lymph:15.6 %, mono:5.0 %, eos:1.2 %, albumin:3.2 g/dl, ldh:342 iu/l, ca++:8.7 mg/dl, mg++:1.9 mg/dl, po4:3.2 mg/dl micro: flu swab negative sputum cx - gram stain (final [**2137-1-19**]): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram positive cocci. in pairs and clusters. 2+ (1-5 per 1000x field): gram positive rod(s). 2+ (1-5 per 1000x field): gram negative rod(s). fluid cx (prelim) gpc in clusters bcx pending imaging: [**1-19**] echo the left atrium is mildly dilated. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). there is abnormal septal motion. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is a small pericardial effusion. the effusion is echo dense, consistent with blood, inflammation or other cellular elements. there is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. cine loop #27 demonstrates transient flattening of interventricular septum during inspiration, suggesting ventricular interdependence and analogous to a physical kussmaul's sign. the echo findings are therefore suggestive of pericardial constriction. no evidence of cardiac tamponade. impression: small residual echodense pericardial effusion. echocardiographic findings are strongly suggestive of effusive-constrictive physiology. compared with the prior study (images reviewed) of [**2137-1-18**], there is evidence of constrictive physiology. the other findings are similar. assessment and plan 32 year old man with no significant medical history presenting with pericardial effusion and early signs of tamponade now stable status post drainage. . # pericardial effusion: most likely viral process. no purulent drainage to suggest bacterial, but fluid cx prelim positive for gpc in clusters - ?contaminant. no history to suggest malignant or tb, fluid cx negative for afb. pt flu negative here, as well as osh. other etiologies appear less likely. drain pulled yesterday minimal fluid seen on echo. echo also with constrictive physiology. -- follow up pericardial studies -- pain control with tylenol, -- indomethacin and colchicine for pericardial inflammation -- repeat echo tomorrow . # ?pneumonia: continued fevers despite antibiotics over past 10 days for community acquired pna. diagnosis appeared to be in question, however sputum with gnrs and gpcs. pt started on vanc/levo/cefepime. - continue vanc/levo/cefepime for now - f/u sputum cx and change abx prn - ?ceftriaxone/azithro - incentive spirometry . # tachycardia: sinus, related to pain and inflammatory state. treat with analgesics per above. fluids. . fen: regular diet. . access: piv's . prophylaxis: -dvt ppx with heparin sc tid -pain management per above -bowel regimen: colace, senna . code: full . comm: [**name (ni) **] and [**name2 (ni) 757**] . dispo: called out to floor icu care nutrition: glycemic control: lines: 20 gauge - [**2137-1-18**] 07:01 pm 22 gauge - [**2137-1-18**] 07:02 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: full code disposition: ------ protected section ------ cardiology teaching physician note on this day i saw, examined and was physically present with the resident / fellow for the key portions of the services provided. i agree with the above note and plans. i have also reviewed the notes of dr(s). [**name (ni) **] and [**doctor last name 980**]. i would add the following remarks: medical decision making patient much more comfortable. echo with evidence on constriction and still with small rim of pericardial effusion. culture was gpc in one bottle only and ;ikely represents a contaminant. he remains on vanco and cefipime. lfts remain elevated which may be a part of a viral syndrome. ok to transfer to the floor as we follow up cultures. would check one more echo prior to discharge. above discussed extensively with patient. i have discussed this plan with dr(s). [**name (ni) **], [**doctor last name **]. total time spent on patient care: 40 minutes of critical care time. ------ protected section addendum entered by:[**name (ni) **] [**last name (namepattern1) **], md on:[**2137-1-20**] 11:38 am ------",1
353,"title: chief complaint: 24 hour events: - echo: small residual pericardial effusion, effusive-constrictive physiology - thoracics aware - fluid gram stain negative, prelim cx no growth, no afb - started on colchicine (cope trial) - pcn allergy confirmed rash on legs, switched aztreonam to cefepime, will monitor for adverse reaction - dfa negative x2, sent third sample; can also wait for culture from first swab (ready in 48h) - fluid cx: gpc in clusters pain with deep inspiration. allergies: penicillins- leg rash last dose of antibiotics: aztreonam - [**2137-1-19**] 07:00 am vancomycin - [**2137-1-19**] 10:00 pm levofloxacin - [**2137-1-19**] 10:00 pm cefipime - [**2137-1-20**] 04:00 am infusions: other icu medications: morphine sulfate - [**2137-1-19**] 11:30 am heparin sodium (prophylaxis) - [**2137-1-19**] 10:00 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2137-1-20**] 07:41 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.6 c (99.6 tcurrent: 36.3 c (97.3 hr: 97 (85 - 113) bpm bp: 141/89(100) {112/51(67) - 149/93(103)} mmhg rr: 23 (15 - 39) insp/min spo2: 95% heart rhythm: sr (sinus rhythm) height: 67 inch total in: 4,975 ml 127 ml po: 2,950 ml tf: ivf: 2,025 ml 127 ml blood products: total out: 5,250 ml 550 ml urine: 5,250 ml 550 ml ng: stool: drains: balance: -275 ml -423 ml respiratory support o2 delivery device: nasal cannula spo2: 95% abg: ///26/ physical examination general: wdwn tachypneic taking shallow breaths speaking in broken sentences. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 10 cm. +kussmaul s sign cardiac: pmi located in 5th intercostal space, midclavicular line. tachycardic, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. pericardial drain pulled, dressing c/d/i. lungs: no chest wall deformities, scoliosis or kyphosis. decreased breath sounds at bases. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominal bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ labs / radiology 476 k/ul 10.1 g/dl 108 mg/dl 0.9 mg/dl 26 meq/l 4.5 meq/l 11 mg/dl 104 meq/l 141 meq/l 30.6 % 6.1 k/ul [image002.jpg] [**2137-1-18**] 08:45 pm [**2137-1-19**] 05:17 am [**2137-1-20**] 06:28 am wbc 8.4 8.6 6.1 hct 27.0 28.4 30.6 plt [**telephone/fax (3) 9849**] cr 0.9 0.8 0.9 tropt <0.01 glucose 171 103 108 other labs: pt / ptt / inr:15.0/30.9/1.3, ck / ckmb / troponin-t:65//<0.01, alt / ast:242/124, alk phos / t bili:163/0.5, differential-neuts:77.7 %, lymph:15.6 %, mono:5.0 %, eos:1.2 %, albumin:3.2 g/dl, ldh:342 iu/l, ca++:8.7 mg/dl, mg++:1.9 mg/dl, po4:3.2 mg/dl micro: flu swab negative sputum cx - gram stain (final [**2137-1-19**]): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram positive cocci. in pairs and clusters. 2+ (1-5 per 1000x field): gram positive rod(s). 2+ (1-5 per 1000x field): gram negative rod(s). fluid cx (prelim) gpc in clusters bcx pending imaging: [**1-19**] echo the left atrium is mildly dilated. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). there is abnormal septal motion. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is a small pericardial effusion. the effusion is echo dense, consistent with blood, inflammation or other cellular elements. there is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. cine loop #27 demonstrates transient flattening of interventricular septum during inspiration, suggesting ventricular interdependence and analogous to a physical kussmaul's sign. the echo findings are therefore suggestive of pericardial constriction. no evidence of cardiac tamponade. impression: small residual echodense pericardial effusion. echocardiographic findings are strongly suggestive of effusive-constrictive physiology. compared with the prior study (images reviewed) of [**2137-1-18**], there is evidence of constrictive physiology. the other findings are similar. assessment and plan 32 year old man with no significant medical history presenting with pericardial effusion and early signs of tamponade now stable status post drainage. . # pericardial effusion: most likely viral process. no purulent drainage to suggest bacterial, but fluid cx prelim positive for gpc in clusters - ?contaminant. no history to suggest malignant or tb, fluid cx negative for afb. pt flu negative here, as well as osh. other etiologies appear less likely. drain pulled yesterday minimal fluid seen on echo. echo also with constrictive physiology. -- follow up pericardial studies -- pain control with tylenol, -- indomethacin and colchicine for pericardial inflammation -- repeat echo tomorrow . # ?pneumonia: continued fevers despite antibiotics over past 10 days for community acquired pna. diagnosis appeared to be in question, however sputum with gnrs and gpcs. pt started on vanc/levo/cefepime. - continue vanc/levo/cefepime for now - f/u sputum cx and change abx prn - ?ceftriaxone/azithro - incentive spirometry . # tachycardia: sinus, related to pain and inflammatory state. treat with analgesics per above. fluids. . fen: regular diet. . access: piv's . prophylaxis: -dvt ppx with heparin sc tid -pain management per above -bowel regimen: colace, senna . code: full . comm: [**name (ni) **] and [**name2 (ni) 757**] . dispo: called out to floor icu care nutrition: glycemic control: lines: 20 gauge - [**2137-1-18**] 07:01 pm 22 gauge - [**2137-1-18**] 07:02 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: full code disposition:",1
354,"title: chief complaint: 24 hour events: - echo: small residual pericardial effusion, effusive-constrictive physiology - thoracics aware - fluid gram stain negative, prelim cx no growth, no afb - started on colchicine (cope trial) - pcn allergy confirmed rash on legs, switched aztreonam to cefepime, will monitor for adverse reaction - dfa negative x2, sent third sample; can also wait for culture from first swab (ready in 48h) - fluid cx: gpc in clusters allergies: penicillins- leg rash last dose of antibiotics: aztreonam - [**2137-1-19**] 07:00 am vancomycin - [**2137-1-19**] 10:00 pm levofloxacin - [**2137-1-19**] 10:00 pm cefipime - [**2137-1-20**] 04:00 am infusions: other icu medications: morphine sulfate - [**2137-1-19**] 11:30 am heparin sodium (prophylaxis) - [**2137-1-19**] 10:00 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2137-1-20**] 07:41 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.6 c (99.6 tcurrent: 36.3 c (97.3 hr: 97 (85 - 113) bpm bp: 141/89(100) {112/51(67) - 149/93(103)} mmhg rr: 23 (15 - 39) insp/min spo2: 95% heart rhythm: sr (sinus rhythm) height: 67 inch total in: 4,975 ml 127 ml po: 2,950 ml tf: ivf: 2,025 ml 127 ml blood products: total out: 5,250 ml 550 ml urine: 5,250 ml 550 ml ng: stool: drains: balance: -275 ml -423 ml respiratory support o2 delivery device: nasal cannula spo2: 95% abg: ///26/ physical examination general: wdwn tachypneic taking shallow breaths speaking in broken sentences. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with jvp of 10 cm. +kussmaul s sign cardiac: pmi located in 5th intercostal space, midclavicular line. tachycardic, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. pericardial drain pulled, dressing c/d/i. lungs: no chest wall deformities, scoliosis or kyphosis. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominal bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ left: carotid 2+ femoral 2+ popliteal 2+ dp 2+ pt 2+ labs / radiology 476 k/ul 10.1 g/dl 108 mg/dl 0.9 mg/dl 26 meq/l 4.5 meq/l 11 mg/dl 104 meq/l 141 meq/l 30.6 % 6.1 k/ul [image002.jpg] [**2137-1-18**] 08:45 pm [**2137-1-19**] 05:17 am [**2137-1-20**] 06:28 am wbc 8.4 8.6 6.1 hct 27.0 28.4 30.6 plt [**telephone/fax (3) 9849**] cr 0.9 0.8 0.9 tropt <0.01 glucose 171 103 108 other labs: pt / ptt / inr:15.0/30.9/1.3, ck / ckmb / troponin-t:65//<0.01, alt / ast:242/124, alk phos / t bili:163/0.5, differential-neuts:77.7 %, lymph:15.6 %, mono:5.0 %, eos:1.2 %, albumin:3.2 g/dl, ldh:342 iu/l, ca++:8.7 mg/dl, mg++:1.9 mg/dl, po4:3.2 mg/dl micro: flu swab negative sputum cx - gram stain (final [**2137-1-19**]): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram positive cocci. in pairs and clusters. 2+ (1-5 per 1000x field): gram positive rod(s). 2+ (1-5 per 1000x field): gram negative rod(s). fluid cx (prelim) gpc in clusters bcx pending imaging: [**1-19**] echo the left atrium is mildly dilated. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). there is abnormal septal motion. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are structurally normal. mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is a small pericardial effusion. the effusion is echo dense, consistent with blood, inflammation or other cellular elements. there is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. cine loop #27 demonstrates transient flattening of interventricular septum during inspiration, suggesting ventricular interdependence and analogous to a physical kussmaul's sign. the echo findings are therefore suggestive of pericardial constriction. no evidence of cardiac tamponade. impression: small residual echodense pericardial effusion. echocardiographic findings are strongly suggestive of effusive-constrictive physiology. compared with the prior study (images reviewed) of [**2137-1-18**], there is evidence of constrictive physiology. the other findings are similar. assessment and plan 32 year old man with no significant medical history presenting with pericardial effusion and early signs of tamponade now stable status post drainage. . # pericardial effusion: no purulent drainage to suggest bacterial, but fluid cx prelim positive for gpc in clusters. no history to suggest malignant or tb, fluid cx negative for afb. pt flu negative here, as well as osh. other etiologies appear less likely. drain pulled yesterday minimal fluid seen on echo. echo also with constrictive physiology. -- follow up pericardial studies -- pain control with tylenol, nsaids for pericardial inflammation -- continue to monitor drain -- f/u pulsus . # ?pneumonia: continued fevers despite antibiotics over past 10 days for community acquired pna. diagnosis appeared to be in question, however sputum with gnrs and gpcs. pt started on vanc/levo/cefepime. - continue vanc/levo/cefepime . # tachycardia: sinus, related to pain and inflammatory state. treat with analgesics per above. fluids. . fen: regular diet. . access: piv's . prophylaxis: -dvt ppx with heparin sc tid -pain management per above -bowel regimen: colace, senna . code: full . comm: [**name (ni) **] and [**name2 (ni) 757**] . dispo: called out to floor icu care nutrition: glycemic control: lines: 20 gauge - [**2137-1-18**] 07:01 pm 22 gauge - [**2137-1-18**] 07:02 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: full code disposition:",1
355,"51year old womad with esld due to alcohol cirrhosis complicated by hrs requiring hemodialysis now s/p orthotopic liver and kidney transplant, transferred back to sicu for management of rapid afib, then brought to or for abdominal washout, small bowel resection. respiratory failure, acute (not ards/[**doctor last name 2**]) assessment: pt intubated on cmv, 40% fio2 with rr mid 20s, o2 sats = 100%, tidal volumes 400s, lungs with bilat rhonci, suctioned for moderate amounts of thick tan sputum. pt continues to be fluid overloaded, + generalized edema. action: pt changed to cpap & pressure support 15/5, 10 mg lasix iv x2 given as ordered response: respiratory status stable, rr mid 20s, tidal volumes 400s, pt approx 2 l neg at 18:00 plan: continue to wean vent as tolerated, diurese as bp tolerates atrial fibrillation (afib) assessment: hr 90s, sr with occasional pvcs, pacs, on amiodorone gtt at 0.5 mg/min action: 400 mg amiodorone po given as ordered, gtt continues as above rate per drs. [**name5 (ptitle) 10193**] & [**name (ni) 7645**], pt to get several doses of amioodorone before gtt is turned off. response: hr 60s-70s, sr no ectopy. plan: continue to monitor hr, bp, administer po amio & wean amio gtt as tolerated anemia, other assessment: hct =24.9 action: 2 units prbcs given response: no adverse reaction noted, repeat hct 32.8 plan: continue to monitor labs, monitor for bleeding. transplant, liver assessment: pt intubated, on propofol 15 mcgs/kg/min and fentanyl 62.5 mcgs/hr for sedation, opens eyes spontaneously and follows commands consistently. shakes head to questions re: pain. moves all extremities on bed. pupils 3 mm equal & reactive. abdomen soft, distended, + bs. pt vomited small amount of yellow fluid, ng tube to low continuous suction with 250 cc out yellow fluid. trophic tube feeds at 10 cc/hr. flexiseal with brown liquid stool draining. foley catheter draining adequate amounts of clear yellow urine. abdominal incision with open area, packed with wet to dry dressing, incision draining moderate amounts serous fluid. jp x1 draining serous fluid. multipodus boots in place. action: 25 mcg boluses of fentanyl iv x2 given for pain. ngt started to drain bilious fluid, tf stopped. response: gi status stable, no other vomiting noted. ngt continues to lcs. plan: hold tf for several days per transplant team, monitor ng output. 18:00: 1.5 mg prograf given as ordered.",0
356,"51year old womad with esld due to alcohol cirrhosis complicated by hrs requiring hemodialysis now s/p orthotopic liver and kidney transplant, transferred back to sicu for management of rapid afib, then brought to or for abdominal washout, small bowel resection. respiratory failure, acute (not ards/[**doctor last name 2**]) assessment: action: response: plan: atrial fibrillation (afib) assessment: action: response: plan: anemia, other assessment: hct =24.7 action: 2 units prbcs given response: no adverse reaction noted, repeat hct 33. plan: continue to monitor labs, monitor for bleeding. transplant, liver assessment: action: response: plan:",0
357,"51year old womad with esld due to alcohol cirrhosis complicated by hrs requiring hemodialysis now s/p orthotopic liver and kidney transplant, transferred back to sicu for management of rapid afib, then brought to or for abdominal washout, small bowel resection. respiratory failure, acute (not ards/[**doctor last name 2**]) assessment: action: response: plan: atrial fibrillation (afib) assessment: hr action: response: plan: anemia, other assessment: hct =24.9 action: 2 units prbcs given response: no adverse reaction noted, repeat hct 32.8 plan: continue to monitor labs, monitor for bleeding. transplant, liver assessment: action: response: plan:",0
358,"58yo female with hypertension, hyperlipidemia, osa, who went to church last evening and noted to be acting strange--poor eye contact, yelling out, not answering questions so she was brought to the ed by her church friends. according to her pastor she was complaining of abdominal pain, having shaking chills, but alert and oriented. significant events: head mri done ultrasound of heart altered mental status (not delirium) assessment: patient received sedated with propofol at 45mcg/kg/min. unable to arouse to stimuli with pinpoint pupils equally brisk to light accommodation and no movement of extremeties. action: weaned off of propofol mri of head done response: patient wakes up to verbal stimuli and follows commands. mae. mri per team was negative. plan: sepsis without organ dysfunction assessment: received patient with temp of 101.6 repeat check was 101.9 orally. lactate from ed was 1.8 and repeated was 3.1. action: patient given tylenol 650mgs via ogt patient on vancomycin, acyclovir, cefepime, ceftriaxone and ampicillin renally dosed. response: blood culture came back positive still unknown origin. lactate trending down currently 1.6 temp trended down. currently______ no adverse reactions from antibiotics noted. plan: continue to follow up final results of cultures. electrolyte & fluid disorder, other assessment: k=3.3 magnesium=1.3 phos 2.3 action: electrolytes repleted: k=40meqs via ogt and 20meqs via iv mg=4grams neutra phos response: plan: continue to monitor electrolytes and replete as necessary",0
359,"56 y/o m with hx of afib, on coumadin, and sbos s/p meckle's diverticulum repair in the past who presents with two days of brbpr and syncope today. starting last weekend, he had noticed some blood in his stool that resolved on it's own. then two days ago had similiar blood in his stool, but this time did not stop. he felt dizzy all day the day prior to admission. he passed out once after urinating. then again he had a large bloody bowel movement and syncopized while on the toilet. he hit his head. ems reported a sbp of about 70 at the time of initial evaluation. his bps have been stable since arrival to the ed. gastrointestinal bleed, other (gi bleed, gib) assessment: received patient with soft non distended abdomen hct=27.3 post 2 units prbc and ffp. no bowel movement with positive bowel sounds. inr 6 from ed down to 1.7 action: 3^rd peripheral access placed hct and inr was monitored 1 unit of prbc given as ordered response: hct 29.8 inr down to 1.3 no adverse reaction from blood transfusion diet advanced to clears no bleeding episodes plan: continue to do serial hcts with inr restart lopressor given that patient has been stable likely transfer to floor in the morning then colonoscopy while on the floor per gi atrial fibrillation (afib) assessment: received patient on afib with rare to occasional pvc s with frequent rapid ventricular rate up to 170 s lasting about 5 secs with stable blood pressure in the 110 s-120 s mmhg systolic action: dr. [**last name (stitle) **] was informed initially planned to hold metoprolol and initiate diltiazem if rvr continues team considered volume resuscitation via 1 unit prbc . response: post transfusion, patient still afib but with less rvr maintained in the 80 s-low 100 s with rare pvc plan: patient was initially planned for outpatient cardioversion with dr. [**last name (stitle) 11483**] from [**hospital1 966**] but patient requested that care be transferred here under dr. [**last name (stitle) **]. team was informed and awaiting consult regarding long term plan with afib.",0
360,"58yo female with hypertension, hyperlipidemia, osa, who went to church last evening and noted to be acting strange--poor eye contact, yelling out, not answering questions so she was brought to the ed by her church friends. according to her pastor she was complaining of abdominal pain, having shaking chills, but alert and oriented. significant events: head mri done ultrasound of heart altered mental status (not delirium) assessment: patient received sedated with propofol at 45mcg/kg/min. unable to arouse to stimuli with pinpoint pupils equally brisk to light accommodation and no movement of extremeties. action: weaned off of propofol mri of head done response: patient wakes up to verbal stimuli and follows commands. mae. mri per team was negative. plan: sepsis without organ dysfunction assessment: received patient with temp of 101.6 repeat check was 101.9 orally. lactate from ed was 1.8 and repeated was 3.1. action: patient given tylenol 650mgs via ogt patient on vancomycin, acyclovir, cefepime, ceftriaxone and ampicillin renally dosed. response: blood culture came back positive still unknown origin. temp trended down. currently______ no adverse reactions from antibiotics noted. plan: continue to follow up final results of cultures.",0
361,"chief complaint: syncope, brbpr hpi: 56 y/o m with hx of afib, on coumadin, and sbos s/p meckle's diverticulum repair in the past who presents with two days of brbpr and syncope today. starting last weekend, he had noticed some blood in his stool that resolved on it's own. then two days ago had similiar blood in his stool, but this time did not stop. he felt dizzy all day the day prior to admission. he passed out once after urinating. then again he had a large bloody bowel movement and syncopized while on the toilet. he hit his head. ems reported a sbp of about 70 at the time of initial evaluation. his bps have been stable since arrival to the ed. allergies: nkda code: full access: 20 gauge x 1, 18 gauge x 2 gastrointestinal bleed, other (gi bleed, gib) assessment: received patient with soft non distended abdomen hct=27.3 post 2 units prbc and ffp. no bowel movement with positive bowel sounds. inr 6 from ed down to 1.7 action: 3^rd peripheral access placed hct and inr was monitored 1 unit of prbc given as ordered response: hct 29.8 inr down to 1.3 no adverse reaction from blood transfusion diet advanced to clears no bleeding episodes plan: continue to do serial hcts with inr restart lopressor given that patient has been stable likely transfer to floor in the morning then colonoscopy while on the floor per gi atrial fibrillation (afib) assessment: received patient on afib with rare to occasional pvc s with frequent rapid ventricular rate up to 170 s lasting about 5 secs with stable blood pressure in the 110 s-120 s mmhg systolic action: dr. [**last name (stitle) **] was informed initially planned to hold metoprolol and initiate diltiazem if rvr continues team considered volume resuscitation via 1 unit prbc . response: post transfusion, patient still afib but with less rvr maintained in the 80 s-low 100 s with rare pvc plan: patient was initially planned for outpatient cardioversion with dr. [**last name (stitle) 11483**] from [**hospital1 966**] but patient requested that care be transferred here under dr. [**last name (stitle) **]. team was informed and awaiting consult regarding long term plan with afib. sleep apnea assessment: received patient with frequent apneic episodes while asleep. o2 sat maintained in 100%. patient had sleep study done years ago and has a machine at home. action: respiratory informed and patient was place on autoset response: tolerated well and comfortable with current face mask than one patient has at home plan: continue autoset when asleep",0
362,"58yo female with hypertension, hyperlipidemia, osa, who went to church last evening and noted to be acting strange--poor eye contact, yelling out, not answering questions so she was brought to the ed by her church friends. according to her pastor she was complaining of abdominal pain, having shaking chills, but alert and oriented. significant events: cxr ct of head, abdomen and pelvis head mri ultrasound of heart blood cultures x 2 sets altered mental status (not delirium) assessment: patient received sedated with propofol at 45mcg/kg/min. unable to arouse to stimuli with pinpoint pupils equally brisk to light accommodation and no movement of extremeties. action: weaned off of propofol mri of head done response: patient wakes up to verbal stimuli and follows commands. mae. oriented x 3 and was extubated. plan: follow up mri results sepsis without organ dysfunction assessment: received patient with temp of 101.6 repeat check was 101.9 orally. lactate from ed was 1.8 and repeated was 3.1. action: patient given tylenol 650mgs via ogtx2 bolused with 1liter of iv ns +5liters from ed cvp 8 patient on vancomycin, acyclovir, cefepime, ceftriaxone and ampicillin renally dosed. blood culture repeated as recommended by id response: blood culture came back positive still unknown origin. lactate trending down currently 1.6 temp fluctuating but responsive with tylenol. tmax 101.9 cvp=13 no adverse reactions from antibiotics noted. hct trending down currently 30.4 from 32.8 plan: continue to follow up final results of cultures. serial cultures daily continue with antibiotics electrolyte & fluid disorder, other assessment: k=3.3 magnesium=1.3 phos 2.3 action: electrolytes repleted: k=40meqs via ogt and 20meqs via iv mg=4grams neutra phos response: k=3.9 mg=2.2 phos=3.0 plan: continue to monitor electrolytes and replete as necessary",0
363,"58yo female with hypertension, hyperlipidemia, osa, who went to church last evening and noted to be acting strange--poor eye contact, yelling out, not answering questions so she was brought to the ed by her church friends. according to her pastor she was complaining of abdominal pain, having shaking chills, but alert and oriented. significant events: cxr ct of head, abdomen and pelvis head mri ultrasound of heart tmax 101.9 blood cultures x 2 sets patient extubated. altered mental status (not delirium) assessment: patient received sedated with propofol at 45mcg/kg/min. unable to arouse to stimuli with pinpoint pupils equally brisk to light accommodation and no movement of extremeties. action: weaned off of propofol mri of head done response: patient wakes up to verbal stimuli and follows commands. mae. oriented x 3 and was extubated. plan: follow up mri results sepsis without organ dysfunction assessment: received patient with temp of 101.6 repeat check was 101.9 orally. lactate from ed was 1.8 and repeated was 3.1. patient with rle cellulitis concerning for necrotizing fac action: patient given tylenol 650mgs via ogtx2 bolused with 1liter of iv ns +5liters from ed cvp 8 patient on vancomycin, acyclovir, cefepime, ceftriaxone and ampicillin renally dosed. blood culture repeated as recommended by id patient seen by surgical, vascular and id team response: blood culture came back positive still unknown origin. lactate trending down currently 1.6 rle with progressing erythema, team aware and area marked temp fluctuating but responsive with tylenol. tmax 101.9 cvp=13 no adverse reactions from antibiotics noted. hct trending down currently 30.4 from 32.8 plan: continue to follow up final results of cultures. serial cultures daily continue with antibiotics electrolyte & fluid disorder, other assessment: k=3.3 magnesium=1.3 phos 2.3 action: electrolytes repleted: k=40meqs via ogt and 20meqs via iv mg=4grams neutra phos response: k=3.9 mg=2.2 phos=3.0 plan: continue to monitor electrolytes and replete as necessary airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) assessment: received patient intubated on cmv 50%fio2 with peep of 5. clear bilateral breath sounds. action: weaned down to cpap of [**3-20**] oral care per vap protocol suctioned orally thick clear copious secretions ; scant via ett response: patient was able to be extubated around 1630 currently on 50% fio2 of high flow neb satting 98% plan: encourage deep breathing and coughing wean down to nasal cannula as tolerated bipap at night.",0
364,"58yo female with hypertension, hyperlipidemia, osa, who went to church last evening and noted to be acting strange--poor eye contact, yelling out, not answering questions so she was brought to the ed by her church friends. according to her pastor she was complaining of abdominal pain, having shaking chills, but alert and oriented. significant events: cxr ct of head, abdomen and pelvis head mri ultrasound of heart tmax 101.9 blood cultures x 2 sets patient extubated. access: right cvl and left ac 18 gauge altered mental status (not delirium) assessment: patient received sedated with propofol at 45mcg/kg/min. unable to arouse to stimuli with pinpoint pupils equally brisk to light accommodation and no movement of extremeties. action: weaned off of propofol mri of head done response: patient wakes up to verbal stimuli and follows commands. mae. oriented x 3 and was extubated. plan: follow up mri results sepsis without organ dysfunction assessment: received patient with temp of 101.6 repeat check was 101.9 orally. lactate from ed was 1.8 and repeated was 3.1. patient with rle cellulitis concerning for necrotizing fac action: patient given tylenol 650mgs via ogtx2 bolused with 1.5 liters of iv ns +5liters from ed cvp 8 patient on vancomycin, acyclovir, cefepime, ceftriaxone and ampicillin renally dosed. blood culture repeated as recommended by id patient seen by surgical, vascular and id team response: blood culture came back positive still unknown origin. lactate trending down currently 1.6 rle with progressing erythema, team aware and area marked temp fluctuating but responsive with tylenol. tmax 101.9 cvp=13 no adverse reactions from antibiotics noted. hct trending down currently 30.4 from 32.8 plan: continue to follow up final results of cultures. serial cultures daily continue with antibiotics labs in am electrolyte & fluid disorder, other assessment: k=3.3 magnesium=1.3 phos 2.3 action: electrolytes repleted: k=40meqs via ogt and 20meqs via iv mg=4grams neutra phos response: k=3.9 mg=2.2 phos=3.0 plan: continue to monitor electrolytes and replete as necessary airway, inability to protect (risk for aspiration, altered gag, airway clearance, cough) assessment: received patient intubated on cmv 50%fio2 with peep of 5. clear bilateral breath sounds. action: weaned down to cpap of [**3-20**] oral care per vap protocol suctioned orally thick clear copious secretions ; scant via ett response: patient was able to be extubated around 1630 currently on 40% fio2 of high flow neb satting 98% plan: encourage deep breathing and coughing wean down to nasal cannula as tolerated bipap at night.",0
365,"tsicu hpi: 78 yo male s/p extended right colectomy with ileocolic anastomosis (ileum to descending colon) at [**hospital3 1492**] on [**2153-3-5**]. his postop course was significant for a troponin leak, acute renal insufficiency (peak cr 2.2, and atrial fibrillation at the osh. he was then transferred to [**hospital1 1**] for further care. on [**2153-3-13**] he underwent exploratory laparotomy with resection of anastomosis, end ileostomy and [**last name (un) 11576**] gastrostomy for leak at the ileocolonic anastomosis with small perforation. during the post op course he had tube feeds leaking from his jp drain and vac, [**3-26**] dye study showed extraluminal contrast initially seen at the distal antrum and a collection at the jp drain in left lower quadrant consistent with leak. his tf were held and he was started on tpn. since [**4-21**] he has experienced acute deterioration in mental status which propted his transfer to ticu requiring intubation secondary to worsening respiratory acidosis. chief complaint: respiratory distress pmhx: pmh: - cad - cabgx5 ([**2141**]) - icd, - hyperlipidemia, - chronic - a-fib - htn - carotid artery dz (60-70% on left, 50% on right) - cvax2 - diverticulosis - ibs - gout . psh: [**2153-3-5**] right colectomy with ileocolic anastomosis (ileum to descending colon) [**2153-3-13**] rsxn anastomosis and end ileostomy ([**hospital1 1**]) current medications: insulin sc (per insulin flowsheet) sliding scale order date: [**5-7**] @ 1105 2. 1000 ml ns continuous at 100 ml/hr order date: [**5-8**] @ 0414 15. insulin sc 10 unit of regular once on [**2153-5-7**] @ 14:23 order date: [**5-7**] @ 1423 3. acetylcysteine 20% 600 mg po/ng q 8h duration: 3 doses order date: [**5-7**] @ 0519 16. lansoprazole oral disintegrating tab 30 mg po/ng daily order date: [**5-7**] @ 0519 4. albumin 5% (25g / 500ml) 25 g iv q8h duration: 48 hours order date: [**5-7**] @ 1107 17. magnesium sulfate iv sliding scale order date: [**5-7**] @ 0330 5. aspirin 81 mg ng daily give via g-tube. no enteric coated order date: [**5-7**] @ 0519 18. metoprolol tartrate 2.5 mg iv q4h:prn hr > 130's order date: [**5-8**] @ 0040 6. calcium gluconate iv sliding scale order date: [**5-7**] @ 0330 19. metoprolol tartrate 2.5 mg iv once mr2 hr > 130 order date: [**5-8**] @ 0140 7. chlorhexidine gluconate 0.12% oral rinse 15 ml oral [**hospital1 **] use only if patient is on mechanical ventilation. order date: [**5-7**] @ 0325 20. midazolam 0.5-2 mg iv q2h:prn agitation order date: [**5-7**] @ 0350 8. dextrose 50% 12.5 gm iv prn hypoglycemia protocol order date: [**5-7**] @ 0330 21. midazolam 1-20 mg/hr iv drip titrate to comfort while sedated patient must have adequate airway support prior to administration of dose. order date: [**5-7**] @ 2043 9. dextrose 50% 25 gm iv once duration: 1 doses order date: [**5-7**] @ 1423 22. norepinephrine 0.03-0.25 mcg/kg/min iv drip titrate to sbp > 100 sepsis etiology order date: [**5-7**] @ 1342 10. fentanyl citrate 25-100 mcg iv q2h:prn pain order date: [**5-7**] @ 0350 23. potassium chloride iv sliding scale order date: [**5-7**] @ 0330 11. fentanyl citrate 100-500 mcg/hr iv drip infusion 12. glucagon 1 mg im q15min:prn hypoglycemia protocol order date: [**5-7**] @ 0330 25. sodium bicarbonate 50 meq iv once mr1 duration: 1 doses k > 5 order date: [**5-7**] @ 1423 13. heparin iv no initial bolus initial infusion rate: 1450 units/hr goal ptt 50-70 order date: [**5-7**] @ 1636 24 hour events: nasal swab - at [**2153-5-7**] 09:01 am transthoracic echo - at [**2153-5-7**] 10:19 am trans esophageal echo - at [**2153-5-7**] 03:05 pm [**5-7**]: family meeting, plan for cmo in am. still on pressors. oliguric. post operative day: pod#1 - right femoral embolectomy and fem artery repair allergies: ace inhibitors unknown; penicillins unknown; tetracycline unknown; last dose of antibiotics: vancomycin - [**2153-5-5**] 08:00 pm infusions: fentanyl (concentrate) - 100 mcg/hour midazolam (versed) - 3 mg/hour heparin sodium - 1,450 units/hour other icu medications: lansoprazole (prevacid) - [**2153-5-7**] 08:10 am hydromorphone (dilaudid) - [**2153-5-7**] 11:19 am sodium bicarbonate 8.4% (amp) - [**2153-5-7**] 02:31 pm dextrose 50% - [**2153-5-7**] 02:44 pm midazolam (versed) - [**2153-5-7**] 07:00 pm fentanyl - [**2153-5-7**] 11:00 pm metoprolol - [**2153-5-8**] 03:00 am other medications: flowsheet data as of [**2153-5-8**] 04:56 am vital signs hemodynamic monitoring fluid balance 24 hours since [**55**] a.m. tmax: 38.1 c (100.5 t current: 37.4 c (99.3 hr: 109 (104 - 133) bpm bp: 100/54(69) {89/48(63) - 129/73(94)} mmhg rr: 18 (12 - 34) insp/min spo2: 100% heart rhythm: af (atrial fibrillation) wgt (current): 92.4 kg (admission): 91 kg cvp: 8 (6 - 17) mmhg total in: 8,540 ml 682 ml po: tube feeding: iv fluid: 7,233 ml 182 ml blood products: 947 ml 500 ml total out: 1,718 ml 80 ml urine: 518 ml 80 ml ng: 250 ml stool: drains: balance: 6,822 ml 602 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml vt (spontaneous): 384 (384 - 384) ml rr (set): 18 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi: 83 pip: 22 cmh2o plateau: 16 cmh2o compliance: 45.9 cmh2o/ml spo2: 100% abg: 7.50/39/170/26/7 ve: 9.1 l/min pao2 / fio2: 425 physical examination general appearance: no acute distress, cachectic heent: perrl cardiovascular: (rhythm: irregular) respiratory / chest: (expansion: symmetric), (breath sounds: cta bilateral : ) abdominal: soft, non-tender left extremities: (edema: absent), (temperature: cool), (pulse - dorsalis pedis: diminished), (pulse - posterior tibial: diminished) right extremities: (edema: absent), (temperature: cool), (pulse - dorsalis pedis: absent), (pulse - posterior tibial: absent) skin: (incision: clean / dry / intact) neurologic: (awake / alert / oriented: x 1), (responds to: noxious stimuli), no(t) moves all extremities, (rue: weakness), (lue: weakness), (rle: no movement), (lle: no movement), sedated labs / radiology 264 k/ul 7.4 g/dl 160 mg/dl 1.4 mg/dl 26 meq/l 4.7 meq/l 39 mg/dl 108 meq/l 143 meq/l 24.3 % 7.4 k/ul [image002.jpg] [**2153-5-7**] 05:04 am [**2153-5-7**] 08:55 am [**2153-5-7**] 11:47 am [**2153-5-7**] 01:10 pm [**2153-5-7**] 01:19 pm [**2153-5-7**] 02:00 pm [**2153-5-7**] 04:45 pm [**2153-5-7**] 04:56 pm [**2153-5-8**] 01:56 am [**2153-5-8**] 02:22 am wbc 9.2 12.3 7.4 hct 26.4 23.8 26.2 24.3 plt 338 379 264 creatinine 1.2 1.2 1.2 1.4 troponin t 0.73 0.66 tco2 28 25 29 28 31 glucose 192 128 158 160 other labs: pt / ptt / inr:14.0/64.5/1.2, ck / ck-mb / troponin t:1342/15/0.66, alt / ast:18/22, alk-phos / t bili:87/0.8, amylase / lipase:/95, differential-neuts:65.0 %, band:16.0 %, lymph:7.0 %, mono:5.0 %, eos:0.0 %, fibrinogen:625 mg/dl, lactic acid:1.4 mmol/l, albumin:2.0 g/dl, ca:7.9 mg/dl, mg:2.0 mg/dl, po4:3.7 mg/dl assessment and plan alteration in tissue perfusion, impaired skin integrity, ineffective coping, pain control (acute pain, chronic pain), alteration in nutrition, bacteremia, respiratory failure, acute (not ards/[**doctor last name 2**]) assessment and plan: 78m s/p right colectomy, arf and rapid a-fib and s/p ex-lap, washoutout, loa, takedown of anastamosis and diverting ileostomy. bounceback to icu after transfer to floor for acute deterioration in mental status and respiratory acidosis. re-intubated for femoral embolectomy. hd stable. neuro: - seems neurologically intact. - versed for sedation - fentanyl gtt for pain control. - plan on cmo . cvs: h/o cad s/p cabg and afib w/ now embolic event and hypotension from sirs likely [**3-6**] ischemic leg - tte - appropriate volume status, rv dysfuntion, neg veg; tee showing akinesis, ef 35% on pressors, mobile clot to descending aorta, not clear assessment veg - hypotension causing demand ischemia - elevated troponins (0.73, 0.66), trending - levophed and neo for pressor support - h/o afib, aicd and pacer. poor rate control - holding lopressor due to hypotension, resuming digoxin (levels 0.4). - anticoagulation held for bleeding ostomy, now will need anticoagulation given afib and embolic event. - cad s/p cabg. restarted statins, imdur and asa. - ischemic lower extremity from embolization to femorals bilaterally s/p embolectomy. now on hep gtt (goal ptt 50-70). will need bilateraly amputations (bka vs. aka). trending ck (1579, 1342) pulm: h/o copd, now w/ ongoing respiratory distsress from pna and nutritional status - re-intubated for procedure, currently on rate control - copd - nebulizer and inhalers prn - high risk of pulmonary embolism - extensive clots to lower extremities, now on anticoagulation - plan to extubate in am and to be made cmo . gi: s/p r colectomy c/b anastomotic leak now s/p ileostomy w/ g tube - g tube tube feeds - now on hold for impending procedure - h.pylori + - to resume treatment after acute illness resolves (amoxicillin 1 gm, clarithromycin 500 mg all twice daily for [**8-15**] days for h pylori) . fen: chronic poor nutritional status from prolonged hospital course - on tf (isosource 1.5 w/ goal 60ml/hr), following nutritional markers - contraction alkalosis with elevated cr - will provide ivf . renal: renal disease from nafcillin induced interstitial nephritis - dye load from cta - bicarb w/ mucomyst for protection - oliguira w/ fena 0.5 - pre-renal etiology, will aggressively resuscitate - elevated cr 1.4 from 1.2 with contraction alkalosis - concerns for myoglobinuria (ck 1579, 1372) - will continue to trend given ischemic leg and imminent rise, will again resuscitate (acidify urine if needed) . heme: embolic events [**3-6**] afib - hct 26.4, keeping the hct above 25 - heparin gtt w/ ptt goal 50-70 . endo: - riss with adequate blood glucose control. - pre-existing gout - hold allopurinol considering high risk of [**last name (un) 2406**]. . id: - mssa bacteremia - on vancomycin for 28 days. adverse reaction to levofloxacin and nafcilin. pending picc line. tte negative for endocarditis but will need tee. total course of vancomycin is 28 days for presumed endocarditis/bacteremia. following vancomycin troughs. - h.pylori treatment for 14 days to be instituted when stable tld: r-ij, r radial aline, foley, gt, ileostomy, wound vac . consults: surgery, neurology, geriatrics, id, ir, vascular billing diagnosis: pna, sepsis, embolism, respiratory failure, ventilator dependence, bacteremia icu care nutrition: glycemic control: riss lines: multi lumen - [**2153-4-23**] 10:30 pm 20 gauge - [**2153-5-6**] 11:00 pm arterial line - [**2153-5-7**] 03:34 am prophylaxis: dvt: scd, hep gtt stress ulcer: ppi vap bundle: + comments: communication: comments: code status: dnr but not dni will be cmo disposition: cmo total time spent: 30 min",1
366,"tsicu hpi: 78 yo male s/p extended right colectomy with ileocolic anastomosis (ileum to descending colon) at [**hospital3 1492**] on [**2153-3-5**]. his postop course was significant for a troponin leak, acute renal insufficiency (peak cr 2.2, and atrial fibrillation at the osh. he was then transferred to [**hospital1 1**] for further care. on [**2153-3-13**] he underwent exploratory laparotomy with resection of anastomosis, end ileostomy and [**last name (un) 11576**] gastrostomy for leak at the ileocolonic anastomosis with small perforation. during the post op course he had tube feeds leaking from his jp drain and vac, [**3-26**] dye study showed extraluminal contrast initially seen at the distal antrum and a collection at the jp drain in left lower quadrant consistent with leak. his tf were held and he was started on tpn. since [**4-21**] he has experienced acute deterioration in mental status which propted his transfer to ticu requiring intubation secondary to worsening respiratory acidosis. chief complaint: altered mental status pmhx: - cad - cabgx5 ([**2141**]) - icd, - hyperlipidemia, - chronic - a-fib - htn - carotid artery dz (60-70% on left, 50% on right) - cvax2 - diverticulosis - ibs - gout current medications: nac, asa 81, electrolyte ss, dig 0.125mg daily, fentanyl prn, midaz prn, heparin 500u/hr, riss, isosorbide 10 tid, lansoprazole, metoprolol 50 tid, rosuvastatin 24 hour events: blood cultured - at [**2153-5-6**] 02:00 pm surveillance allergies: ace inhibitors unknown; penicillins unknown; tetracycline unknown; last dose of antibiotics: vancomycin - [**2153-5-5**] 08:00 pm infusions: other icu medications: heparin sodium (prophylaxis) - [**2153-5-6**] 03:54 pm heparin sodium - [**2153-5-6**] 10:30 pm hydromorphone (dilaudid) - [**2153-5-7**] 12:00 am midazolam (versed) - [**2153-5-7**] 04:25 am metoprolol - [**2153-5-7**] 04:34 am fentanyl - [**2153-5-7**] 05:12 am other medications: flowsheet data as of [**2153-5-7**] 05:46 am vital signs hemodynamic monitoring fluid balance 24 hours since [**55**] a.m. tmax: 38 c (100.4 t current: 37.3 c (99.1 hr: 103 (87 - 139) bpm bp: 100/53(67) {89/47(59) - 161/79(106)} mmhg rr: 28 (14 - 38) insp/min spo2: 95% heart rhythm: af (atrial fibrillation) wgt (current): 99.5 kg (admission): 91 kg cvp: 11 (4 - 15) mmhg total in: 1,832 ml 2,448 ml po: tube feeding: 1,375 ml iv fluid: 247 ml 1,798 ml blood products: 650 ml total out: 1,320 ml 1,140 ml urine: 920 ml 190 ml ng: stool: drains: balance: 512 ml 1,308 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cpap/psv vt (set): 550 (550 - 550) ml vt (spontaneous): 400 (400 - 400) ml ps : 10 cmh2o rr (set): 14 rr (spontaneous): 28 peep: 5 cmh2o fio2: 40% rsbi deferred: no spon resp pip: 16 cmh2o plateau: 18 cmh2o compliance: 42.3 cmh2o/ml spo2: 95% abg: 7.45/39/161/23/3 ve: 11.6 l/min pao2 / fio2: 403 physical examination general appearance: agitated on vent, overbreathing heent: perrl cardiovascular: (rhythm: irregular) respiratory / chest: (expansion: symmetric), (breath sounds: rhonchorous : ) abdominal: soft, non-distended, tender around ostomy sites left extremities: (edema: 1+), (temperature: warm) right extremities: (edema: 1+), (temperature: warm) skin: (incision: clean / dry / intact, erythema, purulent) neurologic: (responds to: noxious stimuli), moves all extremities, sedated labs / radiology 269 k/ul 8.3 g/dl 217 mg/dl 1.1 mg/dl 23 meq/l 4.1 meq/l 41 mg/dl 108 meq/l 142 meq/l 26.7 % 5.0 k/ul [image002.jpg] [**2153-5-4**] 02:03 am [**2153-5-4**] 02:26 am [**2153-5-5**] 02:00 am [**2153-5-5**] 02:25 am [**2153-5-6**] 01:34 am [**2153-5-6**] 11:56 pm [**2153-5-7**] 01:22 am [**2153-5-7**] 02:06 am [**2153-5-7**] 04:45 am [**2153-5-7**] 05:04 am wbc 4.0 7.1 5.9 4.9 5.0 hct 25.1 25.7 24.9 23.5 21 23 26.7 plt 247 252 285 318 269 creatinine 1.0 1.0 1.2 1.1 tco2 25 26 28 28 glucose 148 137 130 [**telephone/fax (3) 11762**] 217 other labs: pt / ptt / inr:13.3/31.3/1.1, ck / ck-mb / troponin t:33/6/0.63, alt / ast:18/22, alk-phos / t bili:87/0.8, amylase / lipase:/95, differential-neuts:76.0 %, band:3.0 %, lymph:11.0 %, mono:7.0 %, eos:3.0 %, lactic acid:3.5 mmol/l, albumin:2.0 g/dl, ca:8.0 mg/dl, mg:2.1 mg/dl, po4:1.8 mg/dl assessment and plan impaired skin integrity, ineffective coping, pain control (acute pain, chronic pain), alteration in nutrition, bacteremia, respiratory failure, acute (not ards/[**doctor last name 2**]) assessment and plan: 78m s/p right colectomy, arf and rapid a-fib and s/p ex-lap, washoutout, loa, takedown of anastamosis and diverting ileostomy. bounceback to icu after transfer to floor for acute deterioration in mental status and respiratory acidosis. re-intubated for femoral embolectomy. hd stable. neuro: - fentanyl for pain control. - speech & swallow once extubated. - oob & pt once extubated. start mobilization, re-orientation and screening for long-term facility. cvs: - cad - restart statins. increased metoprolol to 75mg tid. asa for af, and cad -> can be lowered to 81mg with equall effectiveness for cad. isosorbide restarted. unsure the reason for digoxin (cad?, paf) but we will restart it today at half of the dose and follow-up on serum levels. - h/o afib, aicd and pacer. [**country 2994**] score is 3. b-blockade for rate control. anticoagulated with heparin. * id suggested tee to absolutely exclude endocarditis as a sequelee to the bactermia. will consider obtaining tee today prior to extubation. f/u repeat bcx2 and we will followed esr. abx for 28 days with vancomycin (stop is at 4/20) but supratherapeutic level for now. * rle pulses non-dopplerable, vascular surgery consulted, cta showed common femoral emboli, femoral embolectomy performed. must lie flat for 24hours post procedure. heparin gtt at 500u/hr per vascular. ck to be trended. pulm: * currently intubated on cpap. will attempt to wean and extubate after tee. - mssa pneumonia complicated by interstial nephritis secondary to methicilin. also rare grwoth of the e.coli. patient clinically improved after vancomycin. - pre-existing copd - start around the clock ipratropium and prn albuterol. gi: - abdomen is soft, g tube that was upsized with dimishing leak. - after acute illness resolved would give proton pump inhibitor, amoxicillin 1 gm, clarithromycin 500 mg all twice daily for [**8-15**] days for h pylori. - will restart tube feeds. no need for prokinetic agents since residuals were none. - ppi per home medication. - pre-existing diverticulitis & ibd - add fiber to tf. fen: - on tf (isosource 1.5 w/ goal 60ml/hr) with follow up with nutritional markers (pre-albumin). - increased triglycerides - consdering starting niacin. statin for cad. renal: * screa back to baseline with adequate urine output. will closely monitor given recent dye load and increased vanc trough. receiving 4 doses of acetylcysteine and completed bicarb gtt during cta. - resolving interstitial nephritis from nafcillin (presumed) with hematuria and bacterial colonization. foley changed on saturday. urine ph acidic. - pre-existing bph - start daxazosin on monday . heme: * transfused 2u prbcs during femoral embolectomy given 700 ebl. hct 26.7. will monitor and consider transfusing if decreases or hypotensive given cardiac history. heparin drip with gioal of aptt 50-70. . endo: - riss with adequate blood glucose control. - pre-existing gout - restart allopurinol. id: - pna resolved by clinical signs. - bacteremia - on empiric vancomycin for 28 days. adverse reaction to levofloxacin and nafcilin. picc to be placed tomroow. tte negative for endocarditis but card recommends tee to be absolutely sure. total course of vancomycin is 28 days for presumed endocarditis/bacteremia. serum levels for vancomycin supratherapeutic - hold for now. picc line placement for plonged course of abx. - h.pylori treatment for 14 days to be instituted on monday tld: r-ij, r radial aline, foley, gt, ileostomy, wound vac . consults: surgery, neurology, geriatrics, id billing diagnosis: glycemic control: riss prophylaxis: dvt - scds, sqh stress ulcer - ppi vap bundle - yes icu consent: yes code status: dnr but not dni disposition: icu",1
367,"tsicu hpi: 78 yo male s/p extended right colectomy with ileocolic anastomosis (ileum to descending colon) at [**hospital3 1492**] on [**2153-3-5**]. his postop course was significant for a troponin leak, acute renal insufficiency (peak cr 2.2, and atrial fibrillation at the osh. he was then transferred to [**hospital1 1**] for further care. on [**2153-3-13**] he underwent exploratory laparotomy with resection of anastomosis, end ileostomy and [**last name (un) 11576**] gastrostomy for leak at the ileocolonic anastomosis with small perforation. during the post op course he had tube feeds leaking from his jp drain and vac, [**3-26**] dye study showed extraluminal contrast initially seen at the distal antrum and a collection at the jp drain in left lower quadrant consistent with leak. his tf were held and he was started on tpn. since [**4-21**] he has experienced acute deterioration in mental status which propted his transfer to ticu requiring intubation secondary to worsening respiratory acidosis. chief complaint: altered mental status pmhx: - cad - cabgx5 ([**2141**]) - icd, - hyperlipidemia, - chronic - a-fib - htn - carotid artery dz (60-70% on left, 50% on right) - cvax2 - diverticulosis - ibs - gout current medications: nac, asa 81, electrolyte ss, dig 0.125mg daily, fentanyl prn, midaz prn, heparin 500u/hr, riss, isosorbide 10 tid, lansoprazole, metoprolol 50 tid, rosuvastatin 24 hour events: blood cultured - at [**2153-5-6**] 02:00 pm surveillance allergies: ace inhibitors unknown; penicillins unknown; tetracycline unknown; last dose of antibiotics: vancomycin - [**2153-5-5**] 08:00 pm infusions: other icu medications: heparin sodium (prophylaxis) - [**2153-5-6**] 03:54 pm heparin sodium - [**2153-5-6**] 10:30 pm hydromorphone (dilaudid) - [**2153-5-7**] 12:00 am midazolam (versed) - [**2153-5-7**] 04:25 am metoprolol - [**2153-5-7**] 04:34 am fentanyl - [**2153-5-7**] 05:12 am other medications: flowsheet data as of [**2153-5-7**] 05:46 am vital signs hemodynamic monitoring fluid balance 24 hours since [**55**] a.m. tmax: 38 c (100.4 t current: 37.3 c (99.1 hr: 103 (87 - 139) bpm bp: 100/53(67) {89/47(59) - 161/79(106)} mmhg rr: 28 (14 - 38) insp/min spo2: 95% heart rhythm: af (atrial fibrillation) wgt (current): 99.5 kg (admission): 91 kg cvp: 11 (4 - 15) mmhg total in: 1,832 ml 2,448 ml po: tube feeding: 1,375 ml iv fluid: 247 ml 1,798 ml blood products: 650 ml total out: 1,320 ml 1,140 ml urine: 920 ml 190 ml ng: stool: drains: balance: 512 ml 1,308 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cpap/psv vt (set): 550 (550 - 550) ml vt (spontaneous): 400 (400 - 400) ml ps : 10 cmh2o rr (set): 14 rr (spontaneous): 28 peep: 5 cmh2o fio2: 40% rsbi deferred: no spon resp pip: 16 cmh2o plateau: 18 cmh2o compliance: 42.3 cmh2o/ml spo2: 95% abg: 7.45/39/161/23/3 ve: 11.6 l/min pao2 / fio2: 403 physical examination general appearance: agitated on vent, overbreathing heent: perrl cardiovascular: (rhythm: irregular) respiratory / chest: (expansion: symmetric), (breath sounds: rhonchorous : ) abdominal: soft, non-distended, tender around ostomy sites left extremities: (edema: 1+), (temperature: warm) right extremities: (edema: 1+), (temperature: warm) skin: (incision: clean / dry / intact, erythema, purulent) neurologic: (responds to: noxious stimuli), moves all extremities, sedated labs / radiology 269 k/ul 8.3 g/dl 217 mg/dl 1.1 mg/dl 23 meq/l 4.1 meq/l 41 mg/dl 108 meq/l 142 meq/l 26.7 % 5.0 k/ul [image002.jpg] [**2153-5-4**] 02:03 am [**2153-5-4**] 02:26 am [**2153-5-5**] 02:00 am [**2153-5-5**] 02:25 am [**2153-5-6**] 01:34 am [**2153-5-6**] 11:56 pm [**2153-5-7**] 01:22 am [**2153-5-7**] 02:06 am [**2153-5-7**] 04:45 am [**2153-5-7**] 05:04 am wbc 4.0 7.1 5.9 4.9 5.0 hct 25.1 25.7 24.9 23.5 21 23 26.7 plt 247 252 285 318 269 creatinine 1.0 1.0 1.2 1.1 tco2 25 26 28 28 glucose 148 137 130 [**telephone/fax (3) 11762**] 217 other labs: pt / ptt / inr:13.3/31.3/1.1, ck / ck-mb / troponin t:33/6/0.63, alt / ast:18/22, alk-phos / t bili:87/0.8, amylase / lipase:/95, differential-neuts:76.0 %, band:3.0 %, lymph:11.0 %, mono:7.0 %, eos:3.0 %, lactic acid:3.5 mmol/l, albumin:2.0 g/dl, ca:8.0 mg/dl, mg:2.1 mg/dl, po4:1.8 mg/dl assessment and plan impaired skin integrity, ineffective coping, pain control (acute pain, chronic pain), alteration in nutrition, bacteremia, respiratory failure, acute (not ards/[**doctor last name 2**]) assessment and plan: 78m s/p right colectomy, arf and rapid a-fib and s/p ex-lap, washoutout, loa, takedown of anastamosis and diverting ileostomy. bounceback to icu after transfer to floor for acute deterioration in mental status and respiratory acidosis. re-intubated for femoral embolectomy. hd stable. neuro: - fentanyl for pain control. - speech & swallow once extubated. - oob & pt once extubated. start mobilization, re-orientation and screening for long-term facility. cvs: - cad - restart statins. increased metoprolol to 75mg tid. asa for af, and cad -> can be lowered to 81mg with equall effectiveness for cad. isosorbide restarted. unsure the reason for digoxin (cad?, paf) but we will restart it today at half of the dose and follow-up on serum levels. - h/o afib, aicd and pacer. [**country 2994**] score is 3. b-blockade for rate control. will discuss restarting long-term anticoagulation with team. * id suggested tee to absolutely exclude endocarditis as a sequelee to the bactermia. will consider obtaining tee today prior to extubation. f/u repeat bcx2 and we will followed esr. abx for 28 days with vancomycin (stop is at 4/20) but supratherapeutic level for now. * rle pulses non-dopplerable, vascular surgery consulted, cta showed common femoral emboli, femoral embolectomy performed. must lie flat for 24hours post procedure. heparin gtt at 500u/hr per vascular. pulm: * currently intubated on cpap. will attempt to wean and extubate after tee. - mssa pneumonia complicated by interstial nephritis secondary to methicilin. also rare grwoth of the e.coli. patient clinically improved after vancomycin. - pre-existing copd - start around the clock ipratropium and prn albuterol. gi: - abdomen is soft, g tube that was upsized with dimishing leak. - after acute illness resolved would give proton pump inhibitor, amoxicillin 1 gm, clarithromycin 500 mg all twice daily for [**8-15**] days for h pylori. - will restart tube feeds. no need for prokinetic agents since residuals were none. - ppi per home medication. - pre-existing diverticulitis & ibd - add fiber to tf. fen: - on tf (isosource 1.5 w/ goal 60ml/hr) with follow up with nutritional markers (pre-albumin). - increased triglycerides - consdering starting niacin. statin for cad. renal: * screa back to baseline with adequate urine output. will closely monitor given recent dye load and increased vanc trough. receiving 4 doses of acetylcysteine and completed bicarb gtt during cta. - resolving interstitial nephritis from nafcillin (presumed) with hematuria and bacterial colonization. foley changed on saturday. urine ph acidic. - pre-existing bph - start daxazosin on monday . heme: * transfused 2u prbcs during femoral embolectomy given 700 ebl. hct 26.7. will monitor and consider transfusing if decreases or hypotensive given cardiac history. - talk to primary team about restarting anticoagulation. . endo: - riss with adequate blood glucose control. - pre-existing gout - restart allopurinol. id: - pna resolved by clinical signs. - bacteremia - on empiric vancomycin for 28 days. adverse reaction to levofloxacin and nafcilin. picc to be placed tomroow. tte negative for endocarditis but card recommends tee to be absolutely sure. total course of vancomycin is 28 days for presumed endocarditis/bacteremia. serum levels for vancomycin supratherapeutic - hold for now. picc line placement for plonged course of abx. - h.pylori treatment for 14 days to be instituted on monday tld: r-ij, r radial aline, foley, gt, ileostomy, wound vac . consults: surgery, neurology, geriatrics, id billing diagnosis: glycemic control: riss prophylaxis: dvt - scds, sqh stress ulcer - ppi vap bundle - yes icu consent: yes code status: dnr but not dni disposition: icu",1
368,"tsicu hpi: 78 yo male s/p extended right colectomy with ileocolic anastomosis (ileum to descending colon) at [**hospital3 1492**] on [**2153-3-5**]. his postop course was significant for a troponin leak, acute renal insufficiency (peak cr 2.2, and atrial fibrillation at the osh. he was then transferred to [**hospital1 1**] for further care. on [**2153-3-13**] he underwent exploratory laparotomy with resection of anastomosis, end ileostomy and [**last name (un) 11576**] gastrostomy for leak at the ileocolonic anastomosis with small perforation. during the post op course he had tube feeds leaking from his jp drain and vac, [**3-26**] dye study showed extraluminal contrast initially seen at the distal antrum and a collection at the jp drain in left lower quadrant consistent with leak. his tf were held and he was started on tpn. since [**4-21**] he has experienced acute deterioration in mental status which propted his transfer to ticu requiring intubation secondary to worsening respiratory acidosis. chief complaint: respiratory distress pmhx: pmh: - cad - cabgx5 ([**2141**]) - icd, - hyperlipidemia, - chronic - a-fib - htn - carotid artery dz (60-70% on left, 50% on right) - cvax2 - diverticulosis - ibs - gout . psh: [**2153-3-5**] right colectomy with ileocolic anastomosis (ileum to descending colon) [**2153-3-13**] rsxn anastomosis and end ileostomy ([**hospital1 1**]) current medications: insulin sc (per insulin flowsheet) sliding scale order date: [**5-7**] @ 1105 2. 1000 ml ns continuous at 100 ml/hr order date: [**5-8**] @ 0414 15. insulin sc 10 unit of regular once on [**2153-5-7**] @ 14:23 order date: [**5-7**] @ 1423 3. acetylcysteine 20% 600 mg po/ng q 8h duration: 3 doses order date: [**5-7**] @ 0519 16. lansoprazole oral disintegrating tab 30 mg po/ng daily order date: [**5-7**] @ 0519 4. albumin 5% (25g / 500ml) 25 g iv q8h duration: 48 hours order date: [**5-7**] @ 1107 17. magnesium sulfate iv sliding scale order date: [**5-7**] @ 0330 5. aspirin 81 mg ng daily give via g-tube. no enteric coated order date: [**5-7**] @ 0519 18. metoprolol tartrate 2.5 mg iv q4h:prn hr > 130's order date: [**5-8**] @ 0040 6. calcium gluconate iv sliding scale order date: [**5-7**] @ 0330 19. metoprolol tartrate 2.5 mg iv once mr2 hr > 130 order date: [**5-8**] @ 0140 7. chlorhexidine gluconate 0.12% oral rinse 15 ml oral [**hospital1 **] use only if patient is on mechanical ventilation. order date: [**5-7**] @ 0325 20. midazolam 0.5-2 mg iv q2h:prn agitation order date: [**5-7**] @ 0350 8. dextrose 50% 12.5 gm iv prn hypoglycemia protocol order date: [**5-7**] @ 0330 21. midazolam 1-20 mg/hr iv drip titrate to comfort while sedated patient must have adequate airway support prior to administration of dose. order date: [**5-7**] @ 2043 9. dextrose 50% 25 gm iv once duration: 1 doses order date: [**5-7**] @ 1423 22. norepinephrine 0.03-0.25 mcg/kg/min iv drip titrate to sbp > 100 sepsis etiology order date: [**5-7**] @ 1342 10. fentanyl citrate 25-100 mcg iv q2h:prn pain order date: [**5-7**] @ 0350 23. potassium chloride iv sliding scale order date: [**5-7**] @ 0330 11. fentanyl citrate 100-500 mcg/hr iv drip infusion 12. glucagon 1 mg im q15min:prn hypoglycemia protocol order date: [**5-7**] @ 0330 25. sodium bicarbonate 50 meq iv once mr1 duration: 1 doses k > 5 order date: [**5-7**] @ 1423 13. heparin iv no initial bolus initial infusion rate: 1450 units/hr goal ptt 50-70 order date: [**5-7**] @ 1636 24 hour events: nasal swab - at [**2153-5-7**] 09:01 am transthoracic echo - at [**2153-5-7**] 10:19 am trans esophageal echo - at [**2153-5-7**] 03:05 pm [**5-7**]: family meeting, plan for cmo in am. still on pressors. oliguric. post operative day: pod#1 - right femoral embolectomy and fem artery repair allergies: ace inhibitors unknown; penicillins unknown; tetracycline unknown; last dose of antibiotics: vancomycin - [**2153-5-5**] 08:00 pm infusions: fentanyl (concentrate) - 100 mcg/hour midazolam (versed) - 3 mg/hour heparin sodium - 1,450 units/hour other icu medications: lansoprazole (prevacid) - [**2153-5-7**] 08:10 am hydromorphone (dilaudid) - [**2153-5-7**] 11:19 am sodium bicarbonate 8.4% (amp) - [**2153-5-7**] 02:31 pm dextrose 50% - [**2153-5-7**] 02:44 pm midazolam (versed) - [**2153-5-7**] 07:00 pm fentanyl - [**2153-5-7**] 11:00 pm metoprolol - [**2153-5-8**] 03:00 am other medications: flowsheet data as of [**2153-5-8**] 04:56 am vital signs hemodynamic monitoring fluid balance 24 hours since [**55**] a.m. tmax: 38.1 c (100.5 t current: 37.4 c (99.3 hr: 109 (104 - 133) bpm bp: 100/54(69) {89/48(63) - 129/73(94)} mmhg rr: 18 (12 - 34) insp/min spo2: 100% heart rhythm: af (atrial fibrillation) wgt (current): 92.4 kg (admission): 91 kg cvp: 8 (6 - 17) mmhg total in: 8,540 ml 682 ml po: tube feeding: iv fluid: 7,233 ml 182 ml blood products: 947 ml 500 ml total out: 1,718 ml 80 ml urine: 518 ml 80 ml ng: 250 ml stool: drains: balance: 6,822 ml 602 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml vt (spontaneous): 384 (384 - 384) ml rr (set): 18 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi: 83 pip: 22 cmh2o plateau: 16 cmh2o compliance: 45.9 cmh2o/ml spo2: 100% abg: 7.50/39/170/26/7 ve: 9.1 l/min pao2 / fio2: 425 physical examination general appearance: no acute distress, cachectic heent: perrl cardiovascular: (rhythm: irregular) respiratory / chest: (expansion: symmetric), (breath sounds: cta bilateral : ) abdominal: soft, non-tender left extremities: (edema: absent), (temperature: cool), (pulse - dorsalis pedis: diminished), (pulse - posterior tibial: diminished) right extremities: (edema: absent), (temperature: cool), (pulse - dorsalis pedis: absent), (pulse - posterior tibial: absent) skin: (incision: clean / dry / intact) neurologic: (awake / alert / oriented: x 1), (responds to: noxious stimuli), no(t) moves all extremities, (rue: weakness), (lue: weakness), (rle: no movement), (lle: no movement), sedated labs / radiology 264 k/ul 7.4 g/dl 160 mg/dl 1.4 mg/dl 26 meq/l 4.7 meq/l 39 mg/dl 108 meq/l 143 meq/l 24.3 % 7.4 k/ul [image002.jpg] [**2153-5-7**] 05:04 am [**2153-5-7**] 08:55 am [**2153-5-7**] 11:47 am [**2153-5-7**] 01:10 pm [**2153-5-7**] 01:19 pm [**2153-5-7**] 02:00 pm [**2153-5-7**] 04:45 pm [**2153-5-7**] 04:56 pm [**2153-5-8**] 01:56 am [**2153-5-8**] 02:22 am wbc 9.2 12.3 7.4 hct 26.4 23.8 26.2 24.3 plt 338 379 264 creatinine 1.2 1.2 1.2 1.4 troponin t 0.73 0.66 tco2 28 25 29 28 31 glucose 192 128 158 160 other labs: pt / ptt / inr:14.0/64.5/1.2, ck / ck-mb / troponin t:1342/15/0.66, alt / ast:18/22, alk-phos / t bili:87/0.8, amylase / lipase:/95, differential-neuts:65.0 %, band:16.0 %, lymph:7.0 %, mono:5.0 %, eos:0.0 %, fibrinogen:625 mg/dl, lactic acid:1.4 mmol/l, albumin:2.0 g/dl, ca:7.9 mg/dl, mg:2.0 mg/dl, po4:3.7 mg/dl assessment and plan alteration in tissue perfusion, impaired skin integrity, ineffective coping, pain control (acute pain, chronic pain), alteration in nutrition, bacteremia, respiratory failure, acute (not ards/[**doctor last name 2**]) assessment and plan: 78m s/p right colectomy, arf and rapid a-fib and s/p ex-lap, washoutout, loa, takedown of anastamosis and diverting ileostomy. bounceback to icu after transfer to floor for acute deterioration in mental status and respiratory acidosis. re-intubated for femoral embolectomy. hd stable. neuro: - seems neurologically intact. - versed for sedation - fentanyl gtt for pain control. - plan on cmo . cvs: h/o cad s/p cabg and afib w/ now embolic event and hypotension from sirs likely [**3-6**] ischemic leg - tte - appropriate volume status, rv dysfuntion, neg veg; tee showing akinesis, ef 35% on pressors, mobile clot to descending aorta, not clear assessment veg - hypotension causing demand ischemia - elevated troponins (0.73, 0.66), trending - levophed and neo for pressor support - h/o afib, aicd and pacer. poor rate control - holding lopressor due to hypotension, resuming digoxin (levels 0.4). - anticoagulation held for bleeding ostomy, now will need anticoagulation given afib and embolic event. - cad s/p cabg. restarted statins, imdur and asa. - ischemic lower extremity from embolization to femorals bilaterally s/p embolectomy. now on hep gtt (goal ptt 50-70). will need bilateraly amputations (bka vs. aka). trending ck (1579, 1342) pulm: h/o copd, now w/ ongoing respiratory distsress from pna and nutritional status - re-intubated for procedure, currently on rate control - copd - nebulizer and inhalers prn - high risk of pulmonary embolism - extensive clots to lower extremities, now on anticoagulation - plan to extubate in am and to be made cmo . gi: s/p r colectomy c/b anastomotic leak now s/p ileostomy w/ g tube - g tube tube feeds - now on hold for impending procedure - h.pylori + - to resume treatment after acute illness resolves (amoxicillin 1 gm, clarithromycin 500 mg all twice daily for [**8-15**] days for h pylori) . fen: chronic poor nutritional status from prolonged hospital course - on tf (isosource 1.5 w/ goal 60ml/hr), following nutritional markers - contraction alkalosis with elevated cr - will provide ivf . renal: renal disease from nafcillin induced interstitial nephritis - dye load from cta - bicarb w/ mucomyst for protection - oliguira w/ fena 0.5 - pre-renal etiology, will aggressively resuscitate - elevated cr 1.4 from 1.2 with contraction alkalosis - concerns for myoglobinuria (ck 1579, 1372) - will continue to trend given ischemic leg and imminent rise, will again resuscitate (acidify urine if needed) . heme: embolic events [**3-6**] afib - hct 26.4, keeping the hct above 25 - heparin gtt w/ ptt goal 50-70 . endo: - riss with adequate blood glucose control. - pre-existing gout - hold allopurinol considering high risk of [**last name (un) 2406**]. . id: - mssa bacteremia - on vancomycin for 28 days. adverse reaction to levofloxacin and nafcilin. pending picc line. tte negative for endocarditis but will need tee. total course of vancomycin is 28 days for presumed endocarditis/bacteremia. following vancomycin troughs. - h.pylori treatment for 14 days to be instituted when stable tld: r-ij, r radial aline, foley, gt, ileostomy, wound vac . consults: surgery, neurology, geriatrics, id, ir, vascular billing diagnosis: pna, sepsis, embolism, respiratory failure, ventilator dependence, bacteremia icu care nutrition: glycemic control: riss lines: multi lumen - [**2153-4-23**] 10:30 pm 20 gauge - [**2153-5-6**] 11:00 pm arterial line - [**2153-5-7**] 03:34 am prophylaxis: dvt: scd, hep gtt stress ulcer: ppi vap bundle: + comments: communication: comments: code status: dnr but not dni will be cmo disposition: cmo total time spent: 30 min",1
369,"tsicu hpi: 78 yo male s/p extended right colectomy with ileocolic anastomosis (ileum to descending colon) at [**hospital3 1492**] on [**2153-3-5**]. his postop course was significant for a troponin leak, acute renal insufficiency (peak cr 2.2, and atrial fibrillation at the osh. he was then transferred to [**hospital1 1**] for further care. on [**2153-3-13**] he underwent exploratory laparotomy with resection of anastomosis, end ileostomy and [**last name (un) 11576**] gastrostomy for leak at the ileocolonic anastomosis with small perforation. during the post op course he had tube feeds leaking from his jp drain and vac, [**3-26**] dye study showed extraluminal contrast initially seen at the distal antrum and a collection at the jp drain in left lower quadrant consistent with leak. his tf were held and he was started on tpn. since [**4-21**] he has experienced acute deterioration in mental status which propted his transfer to ticu requiring intubation secondary to worsening respiratory acidosis. chief complaint: respiratory distress pmhx: pmh: - cad - cabgx5 ([**2141**]) - icd, - hyperlipidemia, - chronic - a-fib - htn - carotid artery dz (60-70% on left, 50% on right) - cvax2 - diverticulosis - ibs - gout . psh: [**2153-3-5**] right colectomy with ileocolic anastomosis (ileum to descending colon) [**2153-3-13**] rsxn anastomosis and end ileostomy ([**hospital1 1**]) current medications: insulin sc (per insulin flowsheet) sliding scale order date: [**5-7**] @ 1105 2. 1000 ml ns continuous at 100 ml/hr order date: [**5-8**] @ 0414 15. insulin sc 10 unit of regular once on [**2153-5-7**] @ 14:23 order date: [**5-7**] @ 1423 3. acetylcysteine 20% 600 mg po/ng q 8h duration: 3 doses order date: [**5-7**] @ 0519 16. lansoprazole oral disintegrating tab 30 mg po/ng daily order date: [**5-7**] @ 0519 4. albumin 5% (25g / 500ml) 25 g iv q8h duration: 48 hours order date: [**5-7**] @ 1107 17. magnesium sulfate iv sliding scale order date: [**5-7**] @ 0330 5. aspirin 81 mg ng daily give via g-tube. no enteric coated order date: [**5-7**] @ 0519 18. metoprolol tartrate 2.5 mg iv q4h:prn hr > 130's order date: [**5-8**] @ 0040 6. calcium gluconate iv sliding scale order date: [**5-7**] @ 0330 19. metoprolol tartrate 2.5 mg iv once mr2 hr > 130 order date: [**5-8**] @ 0140 7. chlorhexidine gluconate 0.12% oral rinse 15 ml oral [**hospital1 **] use only if patient is on mechanical ventilation. order date: [**5-7**] @ 0325 20. midazolam 0.5-2 mg iv q2h:prn agitation order date: [**5-7**] @ 0350 8. dextrose 50% 12.5 gm iv prn hypoglycemia protocol order date: [**5-7**] @ 0330 21. midazolam 1-20 mg/hr iv drip titrate to comfort while sedated patient must have adequate airway support prior to administration of dose. order date: [**5-7**] @ 2043 9. dextrose 50% 25 gm iv once duration: 1 doses order date: [**5-7**] @ 1423 22. norepinephrine 0.03-0.25 mcg/kg/min iv drip titrate to sbp > 100 sepsis etiology order date: [**5-7**] @ 1342 10. fentanyl citrate 25-100 mcg iv q2h:prn pain order date: [**5-7**] @ 0350 23. potassium chloride iv sliding scale order date: [**5-7**] @ 0330 11. fentanyl citrate 100-500 mcg/hr iv drip infusion 12. glucagon 1 mg im q15min:prn hypoglycemia protocol order date: [**5-7**] @ 0330 25. sodium bicarbonate 50 meq iv once mr1 duration: 1 doses k > 5 order date: [**5-7**] @ 1423 13. heparin iv no initial bolus initial infusion rate: 1450 units/hr goal ptt 50-70 order date: [**5-7**] @ 1636 24 hour events: nasal swab - at [**2153-5-7**] 09:01 am transthoracic echo - at [**2153-5-7**] 10:19 am trans esophageal echo - at [**2153-5-7**] 03:05 pm [**5-7**]: family meeting, plan for cmo in am. still on pressors. oliguric. post operative day: pod#1 - right femoral embolectomy and fem artery repair allergies: ace inhibitors unknown; penicillins unknown; tetracycline unknown; last dose of antibiotics: vancomycin - [**2153-5-5**] 08:00 pm infusions: fentanyl (concentrate) - 100 mcg/hour midazolam (versed) - 3 mg/hour heparin sodium - 1,450 units/hour other icu medications: lansoprazole (prevacid) - [**2153-5-7**] 08:10 am hydromorphone (dilaudid) - [**2153-5-7**] 11:19 am sodium bicarbonate 8.4% (amp) - [**2153-5-7**] 02:31 pm dextrose 50% - [**2153-5-7**] 02:44 pm midazolam (versed) - [**2153-5-7**] 07:00 pm fentanyl - [**2153-5-7**] 11:00 pm metoprolol - [**2153-5-8**] 03:00 am other medications: flowsheet data as of [**2153-5-8**] 04:56 am vital signs hemodynamic monitoring fluid balance 24 hours since [**55**] a.m. tmax: 38.1 c (100.5 t current: 37.4 c (99.3 hr: 109 (104 - 133) bpm bp: 100/54(69) {89/48(63) - 129/73(94)} mmhg rr: 18 (12 - 34) insp/min spo2: 100% heart rhythm: af (atrial fibrillation) wgt (current): 92.4 kg (admission): 91 kg cvp: 8 (6 - 17) mmhg total in: 8,540 ml 682 ml po: tube feeding: iv fluid: 7,233 ml 182 ml blood products: 947 ml 500 ml total out: 1,718 ml 80 ml urine: 518 ml 80 ml ng: 250 ml stool: drains: balance: 6,822 ml 602 ml respiratory support o2 delivery device: endotracheal tube ventilator mode: cmv/assist/autoflow vt (set): 500 (500 - 500) ml vt (spontaneous): 384 (384 - 384) ml rr (set): 18 rr (spontaneous): 0 peep: 5 cmh2o fio2: 40% rsbi: 83 pip: 22 cmh2o plateau: 16 cmh2o compliance: 45.9 cmh2o/ml spo2: 100% abg: 7.50/39/170/26/7 ve: 9.1 l/min pao2 / fio2: 425 physical examination general appearance: no acute distress, cachectic heent: perrl cardiovascular: (rhythm: irregular) respiratory / chest: (expansion: symmetric), (breath sounds: cta bilateral : ) abdominal: soft, non-tender left extremities: (edema: absent), (temperature: cool), (pulse - dorsalis pedis: diminished), (pulse - posterior tibial: diminished) right extremities: (edema: absent), (temperature: cool), (pulse - dorsalis pedis: absent), (pulse - posterior tibial: absent) skin: (incision: clean / dry / intact) neurologic: (awake / alert / oriented: x 1), (responds to: noxious stimuli), no(t) moves all extremities, (rue: weakness), (lue: weakness), (rle: no movement), (lle: no movement), sedated labs / radiology 264 k/ul 7.4 g/dl 160 mg/dl 1.4 mg/dl 26 meq/l 4.7 meq/l 39 mg/dl 108 meq/l 143 meq/l 24.3 % 7.4 k/ul [image002.jpg] [**2153-5-7**] 05:04 am [**2153-5-7**] 08:55 am [**2153-5-7**] 11:47 am [**2153-5-7**] 01:10 pm [**2153-5-7**] 01:19 pm [**2153-5-7**] 02:00 pm [**2153-5-7**] 04:45 pm [**2153-5-7**] 04:56 pm [**2153-5-8**] 01:56 am [**2153-5-8**] 02:22 am wbc 9.2 12.3 7.4 hct 26.4 23.8 26.2 24.3 plt 338 379 264 creatinine 1.2 1.2 1.2 1.4 troponin t 0.73 0.66 tco2 28 25 29 28 31 glucose 192 128 158 160 other labs: pt / ptt / inr:14.0/64.5/1.2, ck / ck-mb / troponin t:1342/15/0.66, alt / ast:18/22, alk-phos / t bili:87/0.8, amylase / lipase:/95, differential-neuts:65.0 %, band:16.0 %, lymph:7.0 %, mono:5.0 %, eos:0.0 %, fibrinogen:625 mg/dl, lactic acid:1.4 mmol/l, albumin:2.0 g/dl, ca:7.9 mg/dl, mg:2.0 mg/dl, po4:3.7 mg/dl assessment and plan alteration in tissue perfusion, impaired skin integrity, ineffective coping, pain control (acute pain, chronic pain), alteration in nutrition, bacteremia, respiratory failure, acute (not ards/[**doctor last name 2**]) assessment and plan: 78m s/p right colectomy, arf and rapid a-fib and s/p ex-lap, washoutout, loa, takedown of anastamosis and diverting ileostomy. bounceback to icu after transfer to floor for acute deterioration in mental status and respiratory acidosis. re-intubated for femoral embolectomy. hd stable. neuro: - seems neurologically intact. - versed for sedation - fentanyl gtt for pain control. - plan on cmo . cvs: h/o cad s/p cabg and afib w/ now embolic event and hypotension from sirs likely [**3-6**] ischemic leg - tte - appropriate volume status, rv dysfuntion, neg veg; tee showing akinesis, ef 35% on pressors, mobile clot to descending aorta, not clear assessment veg - hypotension causing demand ischemia - elevated troponins (0.73, 0.66), trending - levophed and neo for pressor support - h/o afib, aicd and pacer. poor rate control - holding lopressor due to hypotension, resuming digoxin (levels 0.4). - anticoagulation held for bleeding ostomy, now will need anticoagulation given afib and embolic event. - cad s/p cabg. restarted statins, imdur and asa. - ischemic lower extremity from embolization to femorals bilaterally s/p embolectomy. now on hep gtt (goal ptt 50-70). will need bilateraly amputations (bka vs. aka). trending ck (1579, 1342) pulm: h/o copd, now w/ ongoing respiratory distsress from pna and nutritional status - re-intubated for procedure, currently on rate control - copd - nebulizer and inhalers prn - high risk of pulmonary embolism - extensive clots to lower extremities, now on anticoagulation - plan to extubate in am and to be made cmo . gi: s/p r colectomy c/b anastomotic leak now s/p ileostomy w/ g tube - g tube tube feeds - now on hold for impending procedure - h.pylori + - to resume treatment after acute illness resolves (amoxicillin 1 gm, clarithromycin 500 mg all twice daily for [**8-15**] days for h pylori) . fen: chronic poor nutritional status from prolonged hospital course - on tf (isosource 1.5 w/ goal 60ml/hr), following nutritional markers - contraction alkalosis with elevated cr - will provide ivf . renal: renal disease from nafcillin induced interstitial nephritis - dye load from cta - bicarb w/ mucomyst for protection - oliguira w/ fena 0.5 - pre-renal etiology, will aggressively resuscitate - elevated cr 1.4 from 1.2 with contraction alkalosis - concerns for myoglobinuria (ck 1579, 1372) - will continue to trend given ischemic leg and imminent rise, will again resuscitate (acidify urine if needed) . heme: embolic events [**3-6**] afib - hct 26.4, keeping the hct above 25 - heparin gtt w/ ptt goal 50-70 . endo: - riss with adequate blood glucose control. - pre-existing gout - hold allopurinol considering high risk of [**last name (un) 2406**]. . id: - mssa bacteremia - on vancomycin for 28 days. adverse reaction to levofloxacin and nafcilin. pending picc line. tte negative for endocarditis but will need tee. total course of vancomycin is 28 days for presumed endocarditis/bacteremia. following vancomycin troughs. - h.pylori treatment for 14 days to be instituted when stable tld: r-ij, r radial aline, foley, gt, ileostomy, wound vac . consults: surgery, neurology, geriatrics, id, ir, vascular billing diagnosis: pna, sepsis, embolism, respiratory failure, ventilator dependence, bacteremia icu care nutrition: glycemic control: riss lines: multi lumen - [**2153-4-23**] 10:30 pm 20 gauge - [**2153-5-6**] 11:00 pm arterial line - [**2153-5-7**] 03:34 am prophylaxis: dvt: scd, hep gtt stress ulcer: ppi vap bundle: + comments: communication: comments: code status: dnr but not dni will be cmo disposition: cmo total time spent: 30 min",1
370,"title: respiratory care: rec d pt on a/c 18/400/+8/50%. ett 7.5, retaped, rotated and secured @ 20 lip. bs are coarse with diminished bases. suctioned for small amounts of thick white secretions. mdi administered as ordered alb/atr with no adverse reactions am abg 7.42/47/87. no rsbi due to trach/peg procedure possibly in or.",0
371,"title: respiratory: rec d pt on a/c 18/400/10+/50%. pt has #7 portex trach. bs are coarse to clear with diminished bases. suctioning for small amounts of tan thick secretions. mdi s administered as ordered of alb/atr with no adverse reactions. pt continues to move around a lot in the bed, and anxious at times. no rsbi done due to increased peep of 10. plan is to wean to psv as tolerated and eventually t/c trials. no abg s noc.",0
372,title: respiratory care: rec d pt on a/c 15/400/+8/50%. ett 7.5 taped @ 21 lip. bs are coarse bilaterally with diminished bases. suctioned for small to moderate amounts of thick yellow/tan secretions. mdi administered as ordered alb/atr with no adverse reactions. am abg 7.44/52/70. no rsbi due to trach/peg procedure today. no further changes noted.,0
373,": lung sounds rll lung sounds: rhonchi rul lung sounds: rhonchi lul lung sounds: rhonchi lll lung sounds: rhonchi respiratory care shift procedures nebs: alb/atr administered with no adverse reactions and tolerated well, no changes following tx. will continue to follow.",0
374,"chief complaint: 24 hour events: lung sounds - rhonchi and crackles sats ~ >95% @ 6 lpm via nc and when face tent is in place, denies shortness of breath, coughing out small amountof yellowish sceretions febrile at 12 mn ? neutropenic fever, tachy 110-120 s denies any headache fever - 102.9 f - [**2170-7-29**] 12:00 am allergies: pollen/hayfever (oral) (homeopathic drugs) unknown; last dose of antibiotics: voriconazole - [**2170-7-28**] 10:00 am acyclovir - [**2170-7-28**] 12:28 pm azithromycin - [**2170-7-28**] 12:28 pm vancomycin - [**2170-7-28**] 07:03 pm meropenem - [**2170-7-29**] 05:24 am infusions: other icu medications: pantoprazole (protonix) - [**2170-7-28**] 12:29 pm other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2170-7-29**] 07:42 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 39.4 c (102.9 tcurrent: 36.9 c (98.5 hr: 101 (88 - 120) bpm bp: 112/64(74) {86/44(54) - 142/72(80)} mmhg rr: 30 (15 - 39) insp/min spo2: 98% heart rhythm: st (sinus tachycardia) total in: 1,658 ml 416 ml po: 240 ml tf: ivf: 1,510 ml 176 ml blood products: 148 ml total out: 380 ml 1,050 ml urine: 380 ml 1,050 ml ng: stool: drains: balance: 1,278 ml -634 ml respiratory support o2 delivery device: nasal cannula, face tent spo2: 98% abg: ///31/ physical examination peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) skin: not assessed neurologic: responds to: not assessed, movement: not assessed, tone: not assessed labs / radiology 47 k/ul 8.3 g/dl 110 mg/dl 0.4 mg/dl 31 meq/l 3.4 meq/l 14 mg/dl 101 meq/l 139 meq/l 24.5 % 0.4 k/ul [image002.jpg] [**2170-7-25**] 08:09 pm [**2170-7-26**] 12:10 am [**2170-7-26**] 03:27 am [**2170-7-26**] 04:13 am [**2170-7-26**] 02:57 pm [**2170-7-27**] 03:49 am [**2170-7-27**] 04:16 pm [**2170-7-28**] 04:17 am [**2170-7-28**] 07:20 am [**2170-7-29**] 04:08 am wbc 0.4 0.3 0.3 0.4 hct 23.8 24.4 16.8 25.4 24.5 plt 39 38 62 68 47 cr 0.6 0.6 0.5 0.4 0.7 0.4 tco2 33 32 glucose 150 150 124 106 92 110 other labs: pt / ptt / inr:30.2/42.2/3.1, alt / ast:25/44, alk phos / t bili:63/0.5, lactic acid:1.2 mmol/l, albumin:2.1 g/dl, ldh:189 iu/l, ca++:7.2 mg/dl, mg++:1.8 mg/dl, po4:3.3 mg/dl imaging: [**2170-7-28**] cxr in comparison with the study of [**7-27**], the streak of atelectasis at the left base has cleared. the hazy opacification involving the lower portion of the right hemithorax persists. this is consistent with the right lower lobe consolidation seen on ct which has expanded to involve part of the right upper lobe. moderate right and small left pleural effusion persists. prominence of the right hilar region could reflect the lymphadenopathy seen on ct that probably represents a reactive process. assessment and plan 61 yo male with cutaneous sq cell ca, previously on chemo and xrt, and relapsing cll, presents with neutropenic fever and hypoxia; found to have rll infiltrate, s/p bronch [**2170-7-25**]. suspicion for pe is low given pt s low plts, and lenis preliminarily neg for dvts . 1) hypoxia/ tachypnea: exacerbated during and after fever spikes. likely due to rll pna. x ray now showing ?developing pleural effusions vs segmental collapse of rll. - ip performed thoracentesis yesterday. removed ~1l. pt symptomatically better. pleural fluid results not diagnostic of exudate. pending pleural fluid culture. - ct chest yesterday showed - no utility to re-bronch at this time. - continue o2 supp, abx (azithromycin day 1 for atypicals, vanc iv day 11 for gp/mrsa, meropenem day 5 for gn/anaerobes, voriconazole day [**4-23**] for empiric fungal), neb treatments, mucomyst with albuterol (monitor for any signs of bronchial spasms) - will switch to posaconazole from voriconazole for possible allergic response (pt spikes fever after each dose of vori) - legionella urinary ag negative. - bronch af culture still pending. 2) neutropenic fevers: pt has a source of fever (rll pna), however, pt has been on broad spectrum abx for 5 days. acyclovir for empiric coverage (day 4). fevers may be related to medications. will peel off unecessary abx once organism is identified and sensitivity studies are completed. - f/u blood cultures, bronch af culture - continue chest pt, incentive spirometry - continue neupogen - po vanc d/c d as pt is c. diff neg. (with new assay that lab is using, was told that neg result x 3 is no longer required to rule out c. diff) - appreciate id recs - hold off on additional ivig given adverse reactions. 3) pancytopenia/cll: pt completed course of rituxan on [**2170-7-23**] - ivig attempted for hypogammaglobulinemia but discontinued due to ?transfusion reaction. - appreciate heme/onc recs 4) anemia hct stable. - hct goal>24, however will defer transfusion for now as pt continues to be febrile. 5) tylenol/alcohol: h/o significant daily alcohol use and requiring tylenol for fever control. pt and pt s wife do not want nsaids for the risk of bleeding in the setting of thrombocytopenia. will monitor lfts- currently no e/o hepatitis. 7) cutaneous sq cell ca - xrt on hold 8) thrush - continue clotrimazole troches 9) fen - cardiac, heart healthy diet, neutropenic, with ensure. also consider megace - pt still complaining of small amounts of diarrhea each day. c.diff negative [**7-25**]. will check crypto, viral cx per id, and if negative give immodium for relief. 10) access - piv, picc 11) ppx - pneumoboots (but pt refusing), encourage ambulation, pantoprazole iv, neutropenic precautions 12) code- dnr but does wish to be intubated, after which pt's wife [**name (ni) 225**] will determine goal of care depending on prognosis for meaningful recovery 13) comm with pt and pt s wife [**name (ni) 225**]; also let pmd (dr. [**first name8 (namepattern2) 228**] [**last name (namepattern1) 229**]) know by email with updates. icu care nutrition: glycemic control: lines: picc line - [**2170-7-24**] 05:00 am prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",1
375,"chief complaint: hypoxemia, tachypnea 24 hour events: pt had thoracentesis with removal of 1l yesterday, improvement of symptoms. pleural fluid not clearly exudate vs. transudate by light criteria. cell ct shows lymphocytic predominance. pending cultures. ivig infusion resumed again last night. had been d ed the night before due to adverse reactions. pt had same reactions last night (fever, rigors, altered mental status). will d/c for now. pt continued to spike overnight. repeat blood cultures sent from picc. also seems to be spiking fevers following voriconazole administration. fever - 102.9 f - [**2170-7-28**] 01:45 am allergies: pollen/hayfever (oral) (homeopathic drugs) unknown; last dose of antibiotics: azithromycin - [**2170-7-25**] 12:19 pm vancomycin - [**2170-7-27**] 08:45 pm voriconazole - [**2170-7-27**] 10:30 pm acyclovir - [**2170-7-28**] 04:30 am meropenem - [**2170-7-28**] 05:53 am infusions: other icu medications: furosemide (lasix) - [**2170-7-27**] 03:25 pm other medications: changes to medical and family history: none review of systems is unchanged from admission except as noted below review of systems: none flowsheet data as of [**2170-7-28**] 06:56 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 39.4 c (102.9 tcurrent: 38.2 c (100.7 hr: 113 (99 - 134) bpm bp: 103/77(54) {89/54(54) - 130/77(86)} mmhg rr: 29 (22 - 44) insp/min spo2: 99% heart rhythm: st (sinus tachycardia) total in: 1,840 ml 352 ml po: tf: ivf: 1,580 ml 204 ml blood products: 260 ml 148 ml total out: 2,300 ml 80 ml urine: 2,300 ml 80 ml ng: stool: drains: balance: -461 ml 272 ml respiratory support o2 delivery device: nasal cannula 6l + face tent 95% (for humidity) spo2: 99% physical examination gen: awake, alert, sitting up in bed, face tent on, tachypneic heent: mm slightly dry, perrl, eomi grossly cv: rrr, no m/r/g, s1 s2 present lungs: anteriorly rhonchi bilaterally; posteriorly decreased breath sounds from mid->base r lung; expiratory rhonchi diffusely over l (upper > lower) abd: soft , ntnd, bs+ ext: 1+pitting edema le bilaterally, pedal pulses present labs / radiology 68 k/ul 5.8 g/dl 92 mg/dl 0.7 mg/dl 27 meq/l 3.3 meq/l 13 mg/dl 100 meq/l 136 meq/l 16.8 % 0.3 k/ul [image002.jpg] legionalla urine ag: negative blood cultures: pending bal tests: all ngtd except acid fast cx (pending) ca 7.4/mg 1.7/ phos 2.8 ldh serum 189 pleural fluid: no pmns/microorganisms - tprotein 1.8, glu 109, ldh 178, alb 1.2 - wbc 300, rbc 310, polys 1, lymph 43, monos 0, eos 2, other 54 (likely mesothelial cells) - tpeff/tpser<0.5, but ldh eff/ldh serum>0.6 (equivocal by light criteria) - culture pending cxr [**2170-7-28**] findings: in comparison with the study of [**7-27**], the streak of atelectasis at the left base has cleared. the hazy opacification involving the lower portion of the right hemithorax persists. this is consistent with the right lower lobe consolidation seen on ct which has expanded to involve part of the right upper lobe. moderate right and small left pleural effusion persists. prominence of the right hilar region could reflect the lymphadenopathy seen on ct that probably represents a reactive process. [**2170-7-25**] 12:15 am [**2170-7-25**] 05:18 am [**2170-7-25**] 08:09 pm [**2170-7-26**] 12:10 am [**2170-7-26**] 03:27 am [**2170-7-26**] 04:13 am [**2170-7-26**] 02:57 pm [**2170-7-27**] 03:49 am [**2170-7-27**] 04:16 pm [**2170-7-28**] 04:17 am wbc 0.3 0.4 0.3 0.3 hct 25.1 23.8 24.4 16.8 plt 48 39 38 62 68 cr 0.6 0.6 0.6 0.6 0.5 0.4 0.7 tco2 33 32 glucose 170 139 150 150 124 106 92 other labs: pt / ptt / inr:30.4/42.8/3.1, alt / ast:25/44, alk phos / t bili:63/0.5, lactic acid:1.2 mmol/l, albumin:2.1 g/dl, ldh:189 iu/l, ca++:7.4 mg/dl, mg++:1.7 mg/dl, po4:2.8 mg/dl assessment and plan 61 yo male with cutaneous sq cell ca, previously on chemo and xrt, and relapsing cll, presents with neutropenic fever and hypoxia; found to have rll infiltrate, s/p bronch [**2170-7-25**]. suspicion for pe is low given pt s low plts, and lenis preliminarily neg for dvts . 1) hypoxia/ tachypnea: exacerbated during and after fever spikes. likely due to rll pna. x ray now showing ?developing pleural effusions vs segmental collapse of rll. - ip performed thoracentesis yesterday. removed ~1l. pt symptomatically better. pleural fluid results not diagnostic of exudate. pending pleural fluid culture. - ct chest yesterday showed - no utility to re-bronch at this time. - continue o2 supp, abx (azithromycin day 1 for atypicals, vanc iv day 11 for gp/mrsa, meropenem day 5 for gn/anaerobes, voriconazole day [**4-23**] for empiric fungal), neb treatments, mucomyst with albuterol (monitor for any signs of bronchial spasms) - will switch to posaconazole from voriconazole for possible allergic response (pt spikes fever after each dose of vori) - legionella urinary ag negative. - bronch af culture still pending. 2) neutropenic fevers: pt has a source of fever (rll pna), however, pt has been on broad spectrum abx for 5 days. acyclovir for empiric coverage (day 4). fevers may be related to medications. will peel off unecessary abx once organism is identified and sensitivity studies are completed. - f/u blood cultures, bronch af culture - continue chest pt, incentive spirometry - continue neupogen - po vanc d/c d as pt is c. diff neg. (with new assay that lab is using, was told that neg result x 3 is no longer required to rule out c. diff) - appreciate id recs - hold off on additional ivig given adverse reactions. 3) pancytopenia/cll: pt completed course of rituxan on [**2170-7-23**] - ivig attempted for hypogammaglobulinemia but discontinued due to ?transfusion reaction. - appreciate heme/onc recs 4) anemia hct stable. - hct goal>24, however will defer transfusion for now as pt continues to be febrile. 5) tylenol/alcohol: h/o significant daily alcohol use and requiring tylenol for fever control. pt and pt s wife do not want nsaids for the risk of bleeding in the setting of thrombocytopenia. will monitor lfts- currently no e/o hepatitis. 7) cutaneous sq cell ca - xrt on hold 8) thrush - continue clotrimazole troches 9) fen - cardiac, heart healthy diet, neutropenic, with ensure. also consider megace - pt still complaining of small amounts of diarrhea each day. c.diff negative [**7-25**]. will check crypto, viral cx per id, and if negative give immodium for relief. 10) access - piv, picc 11) ppx - pneumoboots (but pt refusing), encourage ambulation, pantoprazole iv, neutropenic precautions 12) code- dnr but does wish to be intubated, after which pt's wife [**name (ni) 225**] will determine goal of care depending on prognosis for meaningful recovery 13) comm with pt and pt s wife [**name (ni) 225**]; also let pmd (dr. [**first name8 (namepattern2) 228**] [**last name (namepattern1) 229**]) know by email with updates. icu care nutrition: glycemic control: lines: picc line - [**2170-7-24**] 05:00 am prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",1
376,"chief complaint: septic shock secondary to pneumonia, hypoxemia i saw and examined the patient, and was physically present with the icu resident for key portions of the services provided. i agree with his / her note above, including assessment and plan. hpi: 61 m regionally metastatic cutaneous squamous cell ca, cll admitted with fever and neutropenia on [**7-19**]. course has been complicated by progressive hypoxemic failure, pneumonia and sepsis and bilateral pleural effusions. 24 hour events: fever - 102.9 f - [**2170-7-28**] 01:45 am -blood cultures sent. -resumed ivig but had rigors and tachycardia after infusion. -thoracentesis for 1l on the right. history obtained from [**hospital 19**] medical records allergies: pollen/hayfever (oral) (homeopathic drugs) unknown; last dose of antibiotics: azithromycin - [**2170-7-25**] 12:19 pm acyclovir - [**2170-7-28**] 04:30 am meropenem - [**2170-7-28**] 05:53 am vancomycin - [**2170-7-28**] 08:06 am voriconazole - [**2170-7-28**] 10:00 am infusions: other icu medications: furosemide (lasix) - [**2170-7-27**] 03:25 pm other medications: pantoprazole tessalon perles colace allopurinol filgastrim mvi thiamine verapamil 120, 80 mucomyst changes to medical and family history: pmh, sh, fh and ros are unchanged from admission except where noted above and below review of systems is unchanged from admission except as noted below review of systems: constitutional: fever flowsheet data as of [**2170-7-28**] 11:37 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 39.4 c (102.9 tcurrent: 38.4 c (101.1 hr: 105 (99 - 132) bpm bp: 91/59(65) {89/45(54) - 142/77(87)} mmhg rr: 15 (15 - 40) insp/min spo2: 98% heart rhythm: st (sinus tachycardia) total in: 1,840 ml 1,104 ml po: tf: ivf: 1,580 ml 956 ml blood products: 260 ml 148 ml total out: 2,300 ml 80 ml urine: 2,300 ml 80 ml ng: stool: drains: balance: -461 ml 1,024 ml respiratory support o2 delivery device: nasal cannula fio2: 5 l spo2: 98% physical examination general appearance: mild distress cardiovascular: (s1: normal), (s2: normal) peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) respiratory / chest: (breath sounds: diminished: right base, rhonchorous: bilateral) abdominal: soft, non-tender, bowel sounds present extremities: right: trace, left: trace skin: not assessed neurologic: attentive, responds to: not assessed, oriented (to): x 3, movement: not assessed, tone: not assessed labs / radiology 5.8 g/dl 68 k/ul 92 mg/dl 0.7 mg/dl 27 meq/l 3.3 meq/l 13 mg/dl 100 meq/l 136 meq/l 25.4 % 0.3 k/ul [image002.jpg] [**2170-7-25**] 05:18 am [**2170-7-25**] 08:09 pm [**2170-7-26**] 12:10 am [**2170-7-26**] 03:27 am [**2170-7-26**] 04:13 am [**2170-7-26**] 02:57 pm [**2170-7-27**] 03:49 am [**2170-7-27**] 04:16 pm [**2170-7-28**] 04:17 am [**2170-7-28**] 07:20 am wbc 0.3 0.4 0.3 0.3 hct 25.1 23.8 24.4 16.8 25.4 plt 48 39 38 62 68 cr 0.6 0.6 0.6 0.5 0.4 0.7 tco2 33 32 glucose 139 150 150 124 106 92 other labs: pt / ptt / inr:30.4/42.8/3.1, alt / ast:25/44, alk phos / t bili:63/0.5, lactic acid:1.2 mmol/l, albumin:2.1 g/dl, ldh:189 iu/l, ca++:7.4 mg/dl, mg++:1.7 mg/dl, po4:2.8 mg/dl fluid analysis / other labs: pleural fluid: tp 1.8 ldh 178 glucose 109 cell count - 300 wbc (43%ly, 1% pmn, eo 2%, other 54%) cytology pending imaging: chest ct - bilateral pleural effusions, r greater than l. dense consolidaiton rll. relaxation atelectasis l. microbiology: bal - negative blood - pending legionella urinary ag - negative pleural fluid - gram stain negative; culture pending assessment and plan: 61 m cll, locally advanced scc of the skin admitted with fever and neutropenia. large rll pneumonia and bilateral pleural effusions. dyspnea improved after large volume thoracentesis yesterday. fluid reveals exudate but no evidence of empyema. has diarrhea for the past 4 days or so. 1) febrile neutropenia continue current antibiotics. c. diff recently negative. repeat blood cultures pending. wonder if fevers related to drugs, particularly voriconazole, may be contributing. will speak with id re: changing to micafungin or pre-medication for vori. continue neupogen. avoid ivig given recurrent adverse reaction. 2) hypoxemic respiratory failure continue treatment for pneumonia as above. oob. chest pt. supplemental o2 as needed for spo2 > 90%. follow up culture data and cytology. 3) diarrhea crypto ag, viral culture pending. if negative, will start lomotil or immodium. icu care nutrition: cardiac, neutropenic. glycemic control: none. lines: right picc. picc line - [**2170-7-24**] 05:00 am prophylaxis: dvt: ambulation. holding sc heparin for thrombocytopenia. stress ulcer: pantoprazole. vap: n/a. comments: communication: comments: patient, wife, oncology and id consultants code status: dnr. intubation ok. disposition : stable for transfer to oncology floor. total time spent:",1
377,"chief complaint: septic shock secondary to pneumonia, hypoxemia i saw and examined the patient, and was physically present with the icu resident for key portions of the services provided. i agree with his / her note above, including assessment and plan. hpi: 61 m regionally metastatic cutaneous squamous cell ca, cll admitted with fever and neutropenia on [**7-19**]. course has been complicated by progressive hypoxemic failure, pneumonia and sepsis and bilateral pleural effusions. 24 hour events: fever - 102.9 f - [**2170-7-28**] 01:45 am -blood cultures sent. -resumed ivig but had rigors and tachycardia after infusion. -thoracentesis for 1l on the right. history obtained from [**hospital 19**] medical records allergies: pollen/hayfever (oral) (homeopathic drugs) unknown; last dose of antibiotics: azithromycin - [**2170-7-25**] 12:19 pm acyclovir - [**2170-7-28**] 04:30 am meropenem - [**2170-7-28**] 05:53 am vancomycin - [**2170-7-28**] 08:06 am voriconazole - [**2170-7-28**] 10:00 am infusions: other icu medications: furosemide (lasix) - [**2170-7-27**] 03:25 pm other medications: pantoprazole tessalon perles colace allopurinol filgastrim mvi thiamine verapamil 120, 80 mucomyst changes to medical and family history: pmh, sh, fh and ros are unchanged from admission except where noted above and below review of systems is unchanged from admission except as noted below review of systems: constitutional: fever flowsheet data as of [**2170-7-28**] 11:37 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 39.4 c (102.9 tcurrent: 38.4 c (101.1 hr: 105 (99 - 132) bpm bp: 91/59(65) {89/45(54) - 142/77(87)} mmhg rr: 15 (15 - 40) insp/min spo2: 98% heart rhythm: st (sinus tachycardia) total in: 1,840 ml 1,104 ml po: tf: ivf: 1,580 ml 956 ml blood products: 260 ml 148 ml total out: 2,300 ml 80 ml urine: 2,300 ml 80 ml ng: stool: drains: balance: -461 ml 1,024 ml respiratory support o2 delivery device: nasal cannula fio2: 5 l spo2: 98% physical examination general appearance: mild distress cardiovascular: (s1: normal), (s2: normal) peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) respiratory / chest: (breath sounds: diminished: right base, bronchial: bilateral) abdominal: soft, non-tender, bowel sounds present extremities: right: trace, left: trace skin: erythematous rash over back - stable neurologic: attentive, responds to: not assessed, oriented (to): x 3, movement: not assessed, tone: not assessed labs / radiology 5.8 g/dl 68 k/ul 92 mg/dl 0.7 mg/dl 27 meq/l 3.3 meq/l 13 mg/dl 100 meq/l 136 meq/l 25.4 % 0.3 k/ul [image002.jpg] [**2170-7-25**] 05:18 am [**2170-7-25**] 08:09 pm [**2170-7-26**] 12:10 am [**2170-7-26**] 03:27 am [**2170-7-26**] 04:13 am [**2170-7-26**] 02:57 pm [**2170-7-27**] 03:49 am [**2170-7-27**] 04:16 pm [**2170-7-28**] 04:17 am [**2170-7-28**] 07:20 am wbc 0.3 0.4 0.3 0.3 hct 25.1 23.8 24.4 16.8 25.4 plt 48 39 38 62 68 cr 0.6 0.6 0.6 0.5 0.4 0.7 tco2 33 32 glucose 139 150 150 124 106 92 other labs: pt / ptt / inr:30.4/42.8/3.1, alt / ast:25/44, alk phos / t bili:63/0.5, lactic acid:1.2 mmol/l, albumin:2.1 g/dl, ldh:189 iu/l, ca++:7.4 mg/dl, mg++:1.7 mg/dl, po4:2.8 mg/dl fluid analysis / other labs: pleural fluid: tp 1.8 ldh 178 glucose 109 cell count - 300 wbc (43%ly, 1% pmn, eo 2%, other 54%) cytology pending imaging: chest ct - bilateral pleural effusions, r greater than l. dense consolidaiton rll. relaxation atelectasis l. microbiology: bal - negative blood - pending legionella urinary ag - negative pleural fluid - gram stain negative; culture pending assessment and plan: 61 m cll, locally advanced scc of the skin admitted with fever and neutropenia. large rll pneumonia and bilateral pleural effusions. dyspnea improved after large volume thoracentesis yesterday. fluid reveals exudate but no evidence of empyema. has diarrhea for the past 4 days or so. 1) febrile neutropenia continue current antibiotics. c. diff recently negative. repeat blood cultures pending. wonder if fevers related to drugs, particularly voriconazole, may be contributing. will speak with id re: changing to micafungin or pre-medication for vori. continue neupogen. avoid ivig given recurrent adverse reaction. 2) hypoxemic respiratory failure continue treatment for pneumonia as above. oob. chest pt. supplemental o2 as needed for spo2 > 90%. follow up culture data and cytology. 3) diarrhea crypto ag, viral culture pending. if negative, will start lomotil or immodium. i agree in full with the history, exam, ros and plan and findings of the note of dr. [**last name (stitle) 244**]. i was physically present for the discussion of the plan of care and examination of the patient. i would add that patient with scca now admitted with fever and substantial effusion. he is now s/p thoracentesis with significant improvement in dyspnea but has persistent fever and neutropenia. he has been limited with ivig tolerance and has rigor following voriconazole. on exam rr=38 patient with clear evidence of consolidation in rll region most prominently. he does have subtle dullness to percussion only. cough with deep inspiration noted consistent with some re-expansion of atelectasis. will have to continue to consider antibiotic choices with id and oncology input for long term intervention. he has had improvement with thoracentesis which is encouraging at this time and will continue to wean o2 as tolerated. will need repeat cxr to evaluate for re-accumulation. given persistent tachypnea and quick rise in heart rate with minimal exertion would favor continued close monitoring given compromised respiratory status and likely slow to resolve pulmonary parenchymal process. icu care nutrition: cardiac, neutropenic. glycemic control: none. lines: right picc. picc line - [**2170-7-24**] 05:00 am prophylaxis: dvt: ambulation. holding sc heparin for thrombocytopenia. stress ulcer: pantoprazole. vap: n/a. comments: communication: comments: patient, wife, oncology and id consultants code status: dnr. intubation ok. disposition : icu this am re-evaluate in pm for possible transfer. total time spent: 35",1
378,"demographics day of intubation: day of mechanical ventilation: 0 ideal body weight: 69.9 none ideal tidal volume: 279.6 / 419.4 / 559.2 ml/kg airway airway placement data known difficult intubation: no tracheostomy tube: type: extra length manufacturer: [**last name (un) 1821**] size: 8.0mm cuff management: vol/press: cuff pressure: 27 cmh2o cuff volume: 4 ml / lung sounds rll lung sounds: diminished rul lung sounds: clear lul lung sounds: clear lll lung sounds: diminished secretions sputum color / consistency: white / thin sputum source/amount: suctioned / none ventilation assessment level of breathing assistance: continuous invasive ventilation visual assessment of breathing pattern: pt was having intercostal retractions earlier in shift, ps and peep were increased to decrease wob and make pt more comfortable. assessment of breathing comfort: no response (sleeping / sedated) invasive ventilation assessment: trigger work assessment: triggering synchronously dysynchrony assessment: frequent alarms (high rate) plan next 24-48 hours: wean as tolerated reason for continuing current ventilatory support: intolerant of weaning attempts respiratory care shift procedures bedside procedures: comments: at 0230 pt was given 3cc of 2% lidocaine down trach tube due to continous coughing. pt had no adverse reactions noted, uncotrollable coughing was resolved with this.",0
379,"title: respiratory care pt rec d on f/t @ 40%, bs are clear bilaterally and administered neb of alb/atr with no adverse reactions. pt 02 sats 92-96% on n/c @ [**4-14**] lpm. pt did not require niv noc, vent pulled.",0
380,"chief complaint: 24 hour events: - changed to coreg 3.125 and d/c'd dilt gtt. hrs up to 120s-130s. gave another 3.125 coreg without effect (except bp down to 90s/50s). switched back to lopressor 50mg but increased to tid. then increased again to 75mg tid. hrs 90s overnight. bps 120s. - negative 300 at 3pm so did not get extra lasix (goal even) - inr 3 so gave another 5mg po vit k - called id for abx approval but did not get call back allergies: penicillins rash; last dose of antibiotics: vancomycin - [**2111-3-17**] 01:33 pm ceftazidime - [**2111-3-18**] 02:00 am infusions: other icu medications: other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2111-3-18**] 06:20 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 38.9 c (102.1 tcurrent: 37.6 c (99.7 hr: 92 (75 - 138) bpm bp: 109/65(73) {90/50(62) - 129/160(98)} mmhg rr: 23 (18 - 32) insp/min spo2: 92% heart rhythm: af (atrial fibrillation) wgt (current): 73.4 kg (admission): 73.4 kg height: 68 inch total in: 1,176 ml 290 ml po: 750 ml 240 ml tf: ivf: 426 ml 50 ml blood products: total out: 1,485 ml 175 ml urine: 1,485 ml 175 ml ng: stool: drains: balance: -309 ml 115 ml respiratory support o2 delivery device: nasal cannula spo2: 92% abg: ///26/ physical examination general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no elevation of jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rhonchi heard in [**doctor last name **] segment, no crackles or wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. left upper extremity hematoma. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ labs / radiology 104 k/ul 13.2 g/dl 219 mg/dl 1.5 mg/dl 26 meq/l 4.9 meq/l 51 mg/dl 99 meq/l 134 meq/l 37.7 % 8.1 k/ul [image002.jpg] [**2111-3-16**] 08:39 pm [**2111-3-17**] 03:41 am [**2111-3-17**] 05:49 pm [**2111-3-18**] 03:06 am wbc 8.2 8.2 8.1 hct 42.6 43.3 37.7 plt 99 109 104 cr 1.6 1.6 1.6 1.5 tropt 3.34 3.87 glucose 296 206 219 other labs: pt / ptt / inr:21.0/41.8/2.0, ck / ckmb / troponin-t:1046/31/3.87, alt / ast:157/416, alk phos / t bili:97/1.2, differential-neuts:73.3 %, lymph:19.6 %, mono:5.6 %, eos:0.0 %, ca++:8.3 mg/dl, mg++:2.4 mg/dl, po4:2.7 mg/dl imaging: tte: the left atrium is normal in size. the estimated right atrial pressure is 10-20mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is severely depressed (lvef= 20-25 %). the estimated cardiac index is depressed (<2.0l/min/m2). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). transmitral doppler and tissue velocity imaging are consistent with grade iii/iv (severe) lv diastolic dysfunction. right ventricular chamber size is normal. with moderate global free wall hypokinesis. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the aortic valve leaflets are moderately thickened. trace aortic regurgitation is seen. there may be aortic stenosis with restricted leaflet opening but the overall transvalvular velocity is preserved (which may be secondary to poor ventricular contractile function). the mitral valve leaflets are mildly thickened. mild to moderate ([**12-5**]+) mitral regurgitation is seen. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. there is (at least) mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. . impression: severe left ventricular systolic and diastolic dysfunction. moderate right ventricular hypokinesis. elevated estimated left ventricular filling pressures. mild to moderate mitral regurgitation. at least mild pulmonary hypertension. thoracic aortic dilation. assessment and plan 78 yo male with a history of cad, s/p cabg [**39**] years ago, a fib, htn, dm type 2, transferred for treatment of nstemi and a fib with rvr. # nstemi: the patient has 38 year old bypass grafts, with no more recent interventions. in the setting of type 2 dm, the likelihood that these grafts have restenosed is very high. most likely the stress of having a pneumonia with a fib precipitated this event. - restart heparin drip - continue plavix 75mg daily (s/p 600mg loading at osh) - continue high dose aspirin - hold high dose statin given transaminitis - continue beta blockers - hold ace-i given his acute on chronic renal failure and adverse reaction to lisinopril (hyperkalemia) - plan for cardiac cath when inr less, however trending up, gave vit k yesterday - trend ce's until peak - ekg in am . # systolic heart failure: ef documented to be 20-25% at osh with severe global hypokinesis. likely worsening ef secondary to large nstemi. - lasix boluses for diuresis, goal uop 100cc/hr - monitor electrolytes [**hospital1 **] - tte today to evaluate for fixed wall motion abnormalities and ef - unable to give ace-i given adverse reaction . # atrial fibrillation: patient is in rapid ventricular rate currently. the patient had a run of possible a fib with aberrancy vs. v tach earlier today at osh, likely caused by nstemi. - continue metoprolol tartrate 50mg po bid - continue diltiazem drip - monitor on telemetry - hold coumadin, continue heparin drip for now . # pneumonia: possibly hospital acquired pneumonia given recent hospitalization last week for 'weakness.' - cxr on admission - will continue levaquin started [**2111-3-15**] - will add vancomycin and ceftaz to cover hap . # type 2 dm: - hold home glyburide - sliding scale insulin . # hypertension: - will use metoprolol instead of home propranolol in the attempt to rate control - will restart home amlodipine as needed . # transaminitis: likely secondary to low cardiac output in the setting of a large nstemi, or relative hypotension. at osh, t bili 2.6, direct 0.6, ast 288, alt 170, ap 106. trending up ast now 458, inr 3.9 - continue to trend lfts - hold statins for now . # acute on chronic renal insuficiency: at osh, crn on presentation 1.2, with diuresis increased to 1.5. this could also be secondary to low output state. - continue to trend with diuresis . # chronic thrombocytopenia: - monitor closely with heparin iv . icu care nutrition: npo as may go to cath lab today glycemic control: lines: 22 gauge - [**2111-3-16**] 07:00 pm 20 gauge - [**2111-3-16**] 07:00 pm prophylaxis: dvt: heparin drip stress ulcer: vap: comments: communication: comments: code status: full code disposition: ccu",1
381,"chief complaint: 24 hour events: - intermittent arvr, increased po metoprolol to 75 - on the schedule for cath in am - cxr: edema is better - this am, +sob/crackles on exam, 40 iv lasix, 2 mg iv morphine, 5 mg iv metoprolol, cxr (bp 90s so did not give nitro yet) allergies: penicillins rash; last dose of antibiotics: levofloxacin - [**2111-3-18**] 10:00 am vancomycin - [**2111-3-18**] 12:00 pm ceftazidime - [**2111-3-18**] 03:30 pm infusions: heparin sodium - 600 units/hour other icu medications: metoprolol - [**2111-3-19**] 03:47 am furosemide (lasix) - [**2111-3-19**] 05:15 am morphine sulfate - [**2111-3-19**] 05:15 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2111-3-19**] 05:29 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.8 c (100.1 tcurrent: 37.2 c (98.9 hr: 109 (88 - 144) bpm bp: 90/71(74) {90/57(71) - 144/101(107)} mmhg rr: 26 (17 - 31) insp/min spo2: 98% heart rhythm: af (atrial fibrillation) wgt (current): 73.4 kg (admission): 73.4 kg height: 68 inch total in: 1,223 ml 33 ml po: 840 ml tf: ivf: 383 ml 33 ml blood products: total out: 1,235 ml 280 ml urine: 1,235 ml 280 ml ng: stool: drains: balance: -12 ml -247 ml respiratory support o2 delivery device: high flow neb spo2: 98% abg: //// physical examination general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no elevation of jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rhonchi heard in [**doctor last name **] segment, no crackles or wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. left upper extremity hematoma. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ labs / radiology 117 k/ul 14.1 g/dl 255 1.5 mg/dl 26 meq/l 4.9 meq/l 51 mg/dl 99 meq/l 134 meq/l 41.7 % 9.9 k/ul [image002.jpg] [**2111-3-16**] 08:39 pm [**2111-3-17**] 03:41 am [**2111-3-17**] 05:49 pm [**2111-3-18**] 03:06 am [**2111-3-18**] 12:00 pm [**2111-3-18**] 05:00 pm [**2111-3-19**] 04:31 am wbc 8.2 8.2 8.1 9.9 hct 42.6 43.3 37.7 41.7 plt 99 109 104 117 cr 1.6 1.6 1.6 1.5 tropt 3.34 3.87 glucose 296 206 219 178 255 other labs: pt / ptt / inr:21.0/68.5/2.0, ck / ckmb / troponin-t:1046/31/3.87, alt / ast:109/230, alk phos / t bili:97/1.2, differential-neuts:73.3 %, lymph:19.6 %, mono:5.6 %, eos:0.0 %, ca++:8.3 mg/dl, mg++:2.4 mg/dl, po4:2.7 mg/dl assessment and plan 78 yo male with a history of cad, s/p cabg [**39**] years ago, a fib, htn, dm type 2, transferred for treatment of nstemi and a fib with rvr. # nstemi: the patient has 38 year old bypass grafts, with no more recent interventions. in the setting of type 2 dm, the likelihood that these grafts have restenosed is very high. most likely the stress of having a pneumonia with a fib precipitated this event. - discontinued heparin drip given supratherapeutic inr - continue plavix 75mg daily (s/p 600mg loading at osh) - continue high dose aspirin - hold high dose statin given transaminitis - continue beta blockers - hold ace-i given his acute on chronic renal 1.5 today . # systolic heart failure: ef documented to be 20-25% at osh with severe global hypokinesis. likely worsening ef secondary to large nstemi. new flush edema, likely [**1-5**] to not taking daily lasix. - lasix boluse daily for diuresis, goal -2 lt today - monitor electrolytes [**hospital1 **] - tte showed ef 20-25% (same as osh) with severe systolic and diastolic dysfunction, moderate rv hypokinesis. - unable to give ace-i given adverse reaction . # atrial fibrillation: patient is better rate controlled currently. the patient had a run of possible a fib with aberrancy vs. v tach at osh, likely caused by nstemi. - continue metoprolol tartrate 75mg po qid for rapid a fib, consider increasing to 100 mg qid. - monitor on telemetry - hold coumadin for likely cath today and restart heparin gtt for prophylaxis . # pneumonia: possibly hospital acquired pneumonia given recent hospitalization last week for 'weakness.' pt continues to spike temps overnight up to 102.1 yesterday - will continue levaquin started [**2111-3-15**], and vancomycin and ceftaz started [**2111-3-16**] to cover hap . # type 2 dm: - hold home glyburide - sliding scale insulin . # hypertension: - will use metoprolol instead of home propranolol in the attempt to rate control - will restart home amlodipine as needed . # transaminitis: likely secondary to low cardiac output in the setting of a large nstemi, or relative hypotension. at osh, t bili 2.6, direct 0.6, ast 288, alt 170, ap 106. trending up ast now 458, inr 3.9 - continue to trend lfts - hold statins for now . # acute on chronic renal insuficiency: at osh, crn on presentation 1.2, with diuresis increased to 1.5. this could also be secondary to low output state. - continue to trend with diuresis . # chronic thrombocytopenia: - monitor closely with heparin iv icu care nutrition: glycemic control: lines: 22 gauge - [**2111-3-16**] 07:00 pm 20 gauge - [**2111-3-16**] 07:00 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",1
382,"chief complaint: 24 hour events: - changed to coreg 3.125 and d/c'd dilt gtt. hrs up to 120s-130s. gave another 3.125 coreg without effect (except bp down to 90s/50s). switched back to lopressor 50mg but increased to tid. then increased again to 75mg tid. hrs 90s overnight. bps 120s. - negative 300 at 3pm so did not get extra lasix (goal even) - inr 3 so gave another 5mg po vit k - called id for abx approval but did not get call back pt feels ok this am allergies: penicillins rash; last dose of antibiotics: vancomycin - [**2111-3-17**] 01:33 pm ceftazidime - [**2111-3-18**] 02:00 am infusions: other icu medications: other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2111-3-18**] 06:20 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 38.9 c (102.1 tcurrent: 37.6 c (99.7 hr: 92 (75 - 138) bpm bp: 109/65(73) {90/50(62) - 129/160(98)} mmhg rr: 23 (18 - 32) insp/min spo2: 92% heart rhythm: af (atrial fibrillation) wgt (current): 73.4 kg (admission): 73.4 kg height: 68 inch total in: 1,176 ml 290 ml po: 750 ml 240 ml tf: ivf: 426 ml 50 ml blood products: total out: 1,485 ml 175 ml urine: 1,485 ml 175 ml ng: stool: drains: balance: -309 ml 115 ml respiratory support o2 delivery device: nasal cannula spo2: 92% abg: ///26/ physical examination general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no elevation of jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rhonchi heard in [**doctor last name **] segment, no crackles or wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. left upper extremity hematoma. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ labs / radiology 104 k/ul 13.2 g/dl 219 mg/dl 1.5 mg/dl 26 meq/l 4.9 meq/l 51 mg/dl 99 meq/l 134 meq/l 37.7 % 8.1 k/ul [image002.jpg] [**2111-3-16**] 08:39 pm [**2111-3-17**] 03:41 am [**2111-3-17**] 05:49 pm [**2111-3-18**] 03:06 am wbc 8.2 8.2 8.1 hct 42.6 43.3 37.7 plt 99 109 104 cr 1.6 1.6 1.6 1.5 tropt 3.34 3.87 glucose 296 206 219 other labs: pt / ptt / inr:21.0/41.8/2.0, ck / ckmb / troponin-t:1046/31/3.87, alt / ast:157/416, alk phos / t bili:97/1.2, differential-neuts:73.3 %, lymph:19.6 %, mono:5.6 %, eos:0.0 %, ca++:8.3 mg/dl, mg++:2.4 mg/dl, po4:2.7 mg/dl imaging: tte: the left atrium is normal in size. the estimated right atrial pressure is 10-20mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is severely depressed (lvef= 20-25 %). the estimated cardiac index is depressed (<2.0l/min/m2). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). transmitral doppler and tissue velocity imaging are consistent with grade iii/iv (severe) lv diastolic dysfunction. right ventricular chamber size is normal. with moderate global free wall hypokinesis. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the aortic valve leaflets are moderately thickened. trace aortic regurgitation is seen. there may be aortic stenosis with restricted leaflet opening but the overall transvalvular velocity is preserved (which may be secondary to poor ventricular contractile function). the mitral valve leaflets are mildly thickened. mild to moderate ([**12-5**]+) mitral regurgitation is seen. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. there is (at least) mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. . impression: severe left ventricular systolic and diastolic dysfunction. moderate right ventricular hypokinesis. elevated estimated left ventricular filling pressures. mild to moderate mitral regurgitation. at least mild pulmonary hypertension. thoracic aortic dilation. assessment and plan 78 yo male with a history of cad, s/p cabg [**39**] years ago, a fib, htn, dm type 2, transferred for treatment of nstemi and a fib with rvr. # nstemi: the patient has 38 year old bypass grafts, with no more recent interventions. in the setting of type 2 dm, the likelihood that these grafts have restenosed is very high. most likely the stress of having a pneumonia with a fib precipitated this event. - discontinued heparin drip given supratherapeutic inr - continue plavix 75mg daily (s/p 600mg loading at osh) - continue high dose aspirin - hold high dose statin given transaminitis - continue beta blockers - hold ace-i given his acute on chronic renal failure and adverse reaction to lisinopril (hyperkalemia) - pt may undergo cardiac cath today given inr 2.0 today . # systolic heart failure: ef documented to be 20-25% at osh with severe global hypokinesis. likely worsening ef secondary to large nstemi. - lasix boluses for diuresis, goal to remain even throughout the day - monitor electrolytes [**hospital1 **] - tte yesterday showed ef 20-25% (same as osh) with severe systolic and diastolic dysfunction, moderate rv hypokinesis. - unable to give ace-i given adverse reaction . # atrial fibrillation: patient is better rate controlled currently. the patient had a run of possible a fib with aberrancy vs. v tach at osh, likely caused by nstemi. - continue metoprolol tartrate 75mg po tid for rapid a fib - monitor on telemetry - hold coumadin for likely cath today and restart heparin gtt for prophylaxis . # pneumonia: possibly hospital acquired pneumonia given recent hospitalization last week for 'weakness.' pt continues to spike temps overnight up to 102.1 yesterday - will continue levaquin started [**2111-3-15**], and vancomycin and ceftaz started [**2111-3-16**] to cover hap . # type 2 dm: - hold home glyburide - sliding scale insulin . # hypertension: - will use metoprolol instead of home propranolol in the attempt to rate control - will restart home amlodipine as needed . # transaminitis: likely secondary to low cardiac output in the setting of a large nstemi, or relative hypotension. at osh, t bili 2.6, direct 0.6, ast 288, alt 170, ap 106. trending up ast now 458, inr 3.9 - continue to trend lfts - hold statins for now . # acute on chronic renal insuficiency: at osh, crn on presentation 1.2, with diuresis increased to 1.5. this could also be secondary to low output state. - continue to trend with diuresis . # chronic thrombocytopenia: - monitor closely with heparin iv . icu care nutrition: npo as may go to cath lab today glycemic control: lines: 22 gauge - [**2111-3-16**] 07:00 pm 20 gauge - [**2111-3-16**] 07:00 pm prophylaxis: dvt therapeutic inr restart hep gtt today stress ulcer: vap: comments: communication: comments: code status: full code disposition: ccu ------ protected section ------ agree with dr.[**last name (stitle) 397**] s notes. reviewed dat a and examined pt. spent 35 mins on case. [**first name4 (namepattern1) **] [**last name (namepattern1) 4425**] ------ protected section addendum entered by:[**name (ni) **] [**name (ni) 4425**] on:[**2111-3-18**] 13:01 ------",1
383,"chief complaint: 24 hour events: - intermittent arvr, increased po metoprolol to 75 - on the schedule for cath in am - cxr: edema is better - this am, +sob/crackles on exam, 40 iv lasix, 2 mg iv morphine, 5 mg iv metoprolol, cxr (bp 90s so did not give nitro yet) allergies: penicillins rash; last dose of antibiotics: levofloxacin - [**2111-3-18**] 10:00 am vancomycin - [**2111-3-18**] 12:00 pm ceftazidime - [**2111-3-18**] 03:30 pm infusions: heparin sodium - 600 units/hour other icu medications: metoprolol - [**2111-3-19**] 03:47 am furosemide (lasix) - [**2111-3-19**] 05:15 am morphine sulfate - [**2111-3-19**] 05:15 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2111-3-19**] 05:29 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.8 c (100.1 tcurrent: 37.2 c (98.9 hr: 109 (88 - 144) bpm bp: 90/71(74) {90/57(71) - 144/101(107)} mmhg rr: 26 (17 - 31) insp/min spo2: 98% heart rhythm: af (atrial fibrillation) wgt (current): 73.4 kg (admission): 73.4 kg height: 68 inch total in: 1,223 ml 33 ml po: 840 ml tf: ivf: 383 ml 33 ml blood products: total out: 1,235 ml 280 ml urine: 1,235 ml 280 ml ng: stool: drains: balance: -12 ml -247 ml respiratory support o2 delivery device: high flow neb spo2: 98% abg: //// physical examination general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no elevation of jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rhonchi heard in [**doctor last name **] segment, no crackles or wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. left upper extremity hematoma. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ labs / radiology 117 k/ul 14.1 g/dl 255 1.5 mg/dl 26 meq/l 4.9 meq/l 51 mg/dl 99 meq/l 134 meq/l 41.7 % 9.9 k/ul [image002.jpg] [**2111-3-16**] 08:39 pm [**2111-3-17**] 03:41 am [**2111-3-17**] 05:49 pm [**2111-3-18**] 03:06 am [**2111-3-18**] 12:00 pm [**2111-3-18**] 05:00 pm [**2111-3-19**] 04:31 am wbc 8.2 8.2 8.1 9.9 hct 42.6 43.3 37.7 41.7 plt 99 109 104 117 cr 1.6 1.6 1.6 1.5 tropt 3.34 3.87 glucose 296 206 219 178 255 other labs: pt / ptt / inr:21.0/68.5/2.0, ck / ckmb / troponin-t:1046/31/3.87, alt / ast:109/230, alk phos / t bili:97/1.2, differential-neuts:73.3 %, lymph:19.6 %, mono:5.6 %, eos:0.0 %, ca++:8.3 mg/dl, mg++:2.4 mg/dl, po4:2.7 mg/dl assessment and plan 78 yo male with a history of cad, s/p cabg [**39**] years ago, a fib, htn, dm type 2, transferred for treatment of nstemi and a fib with rvr. # nstemi: the patient has 38 year old bypass grafts, with no more recent interventions. in the setting of type 2 dm, the likelihood that these grafts have restenosed is very high. most likely the stress of having a pneumonia with a fib precipitated this event. - discontinued heparin drip given supratherapeutic inr - continue plavix 75mg daily (s/p 600mg loading at osh) - continue high dose aspirin - hold high dose statin given transaminitis - continue beta blockers - hold ace-i given his acute on chronic renal failure and adverse reaction to lisinopril (hyperkalemia) - pt may undergo cardiac cath today given inr 2.0 today . # systolic heart failure: ef documented to be 20-25% at osh with severe global hypokinesis. likely worsening ef secondary to large nstemi. - lasix boluses for diuresis, goal to remain even throughout the day - monitor electrolytes [**hospital1 **] - tte yesterday showed ef 20-25% (same as osh) with severe systolic and diastolic dysfunction, moderate rv hypokinesis. - unable to give ace-i given adverse reaction . # atrial fibrillation: patient is better rate controlled currently. the patient had a run of possible a fib with aberrancy vs. v tach at osh, likely caused by nstemi. - continue metoprolol tartrate 75mg po tid for rapid a fib - monitor on telemetry - hold coumadin for likely cath today and restart heparin gtt for prophylaxis . # pneumonia: possibly hospital acquired pneumonia given recent hospitalization last week for 'weakness.' pt continues to spike temps overnight up to 102.1 yesterday - will continue levaquin started [**2111-3-15**], and vancomycin and ceftaz started [**2111-3-16**] to cover hap . # type 2 dm: - hold home glyburide - sliding scale insulin . # hypertension: - will use metoprolol instead of home propranolol in the attempt to rate control - will restart home amlodipine as needed . # transaminitis: likely secondary to low cardiac output in the setting of a large nstemi, or relative hypotension. at osh, t bili 2.6, direct 0.6, ast 288, alt 170, ap 106. trending up ast now 458, inr 3.9 - continue to trend lfts - hold statins for now . # acute on chronic renal insuficiency: at osh, crn on presentation 1.2, with diuresis increased to 1.5. this could also be secondary to low output state. - continue to trend with diuresis . # chronic thrombocytopenia: - monitor closely with heparin iv icu care nutrition: glycemic control: lines: 22 gauge - [**2111-3-16**] 07:00 pm 20 gauge - [**2111-3-16**] 07:00 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",1
384,"chief complaint: 24 hour events: cardiac cath - at [**2111-3-19**] 09:30 am arterial line - start [**2111-3-19**] 01:00 pm pa catheter - start [**2111-3-19**] 01:24 pm pa catheter - stop [**2111-3-19**] 02:35 pm arterial line - stop [**2111-3-19**] 02:35 pm [**2111-3-19**]: - cath this am: showed 3vd and stenosed venous grafts, pt will need revision cabg. ct [**doctor first name 91**] consulted. plan for revision cabg on tuesday panorex ordered, call dental consult in am [**numeric identifier 5809**], ct chest and carotids ordered, - pt received iv lasix during cath for pulmonary edema - pa pressures low, added 50cc/hr of ns - bg running high, likely secondary to stress and infection, increased sliding scale by 2 units - restarted heparin at 7:30pm allergies: penicillins rash; last dose of antibiotics: levofloxacin - [**2111-3-18**] 10:00 am vancomycin - [**2111-3-19**] 01:30 pm ceftazidime - [**2111-3-19**] 04:00 pm infusions: heparin sodium - 600 units/hour other icu medications: furosemide (lasix) - [**2111-3-19**] 11:30 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2111-3-20**] 06:11 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 38.1 c (100.6 tcurrent: 36.9 c (98.5 hr: 95 (88 - 114) bpm bp: 128/82(94) {111/60(74) - 149/84(97)} mmhg rr: 23 (13 - 33) insp/min spo2: 96% heart rhythm: af (atrial fibrillation) wgt (current): 73.4 kg (admission): 73.4 kg height: 68 inch pap: (19 mmhg) / (12 mmhg) total in: 1,657 ml 137 ml po: 660 ml tf: ivf: 997 ml 137 ml blood products: total out: 2,595 ml 555 ml urine: 2,145 ml 555 ml ng: stool: drains: balance: -938 ml -418 ml respiratory support o2 delivery device: nasal cannula spo2: 96% abg: ///25/ physical examination general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no elevation of jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rhonchi heard in [**doctor last name **] segment, no crackles or wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. left upper extremity hematoma. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ labs / radiology 103 k/ul 12.1 g/dl 212 mg/dl 1.4 mg/dl 25 meq/l 9.0 meq/l 52 mg/dl 94 meq/l 128 meq/l 35.8 % 7.8 k/ul [image002.jpg] [**2111-3-16**] 08:39 pm [**2111-3-17**] 03:41 am [**2111-3-17**] 05:49 pm [**2111-3-18**] 03:06 am [**2111-3-18**] 12:00 pm [**2111-3-18**] 05:00 pm [**2111-3-19**] 04:31 am [**2111-3-19**] 05:20 pm [**2111-3-20**] 04:26 am wbc 8.2 8.2 8.1 9.9 7.8 hct 42.6 43.3 37.7 41.7 35.8 plt 99 109 104 117 103 cr 1.6 1.6 1.6 1.5 1.3 1.4 1.4 tropt 3.34 3.87 glucose 296 206 219 178 255 233 246 212 other labs: pt / ptt / inr:16.0/60.9/1.4, ck / ckmb / troponin-t:1046/31/3.87, alt / ast:109/230, alk phos / t bili:97/1.2, differential-neuts:73.3 %, lymph:19.6 %, mono:5.6 %, eos:0.0 %, ca++:8.4 mg/dl, mg++:2.6 mg/dl, po4:3.3 mg/dl assessment and plan 78 yo male with a history of cad, s/p cabg [**39**] years ago, a fib, htn, dm type 2, transferred for treatment of nstemi and a fib with rvr. # nstemi: cath showed 3vd with occlusion of lad (80%) lcx and rca as well as svg. - cabg next week - continue high dose aspirin - considers starting on statin if transaminitis is better - no plavix - continue beta blockers . # systolic heart failure: ef documented to be 20-25% at osh with severe global hypokinesis. likely worsening ef secondary to large nstemi. new flush edema yesterday. - lasix boluse daily for diuresis, goal -1 lt today - monitor electrolytes [**hospital1 **] - tte showed ef 20-25% (same as osh) with severe systolic and diastolic dysfunction, moderate rv hypokinesis. - unable to give ace-i given adverse reaction . # atrial fibrillation: patient is better rate controlled currently. the patient had a run of possible a fib with aberrancy vs. v tach at osh, likely caused by nstemi. - continue metoprolol tartrate 75mg po qid for rapid a fib, consider increasing to 100 mg qid. - monitor on telemetry - on heparin gtt , transition to warfarin post cabg . # pneumonia: possibly hospital acquired pneumonia given recent hospitalization last week for 'weakness.' pt continues to spike temps overnight up to 102.1 yesterday - will continue levaquin started [**2111-3-15**], and vancomycin and ceftaz started [**2111-3-16**] to cover hap . # type 2 dm: - hold home glyburide - sliding scale insulin # transaminitis: likely secondary to low cardiac output in the setting of a large nstemi, or relative hypotension. improving. - continue to trend lfts (trending down over last few days) - hold statins for now # acute on chronic renal insuficiency: at osh, crn on presentation 1.2, with diuresis increased to 1.5. this could also be secondary to low output state. - continue to trend with diuresis # chronic thrombocytopenia: - monitor closely with heparin iv icu care nutrition: glycemic control: lines: 20 gauge - [**2111-3-19**] 05:00 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",1
385,"chief complaint: 24 hour events: cardiac cath - at [**2111-3-19**] 09:30 am arterial line - start [**2111-3-19**] 01:00 pm pa catheter - start [**2111-3-19**] 01:24 pm pa catheter - stop [**2111-3-19**] 02:35 pm arterial line - stop [**2111-3-19**] 02:35 pm [**2111-3-19**]: - cath this am: showed 3vd and stenosed venous grafts, pt will need revision cabg. ct [**doctor first name 91**] consulted. plan for revision cabg on tuesday panorex ordered, call dental consult in am [**numeric identifier 5809**], ct chest and carotids ordered, - pt received iv lasix during cath for pulmonary edema - pa pressures low, added 50cc/hr of ns - bg running high, likely secondary to stress and infection, increased sliding scale by 2 units - restarted heparin at 7:30pm allergies: penicillins rash; last dose of antibiotics: levofloxacin - [**2111-3-18**] 10:00 am vancomycin - [**2111-3-19**] 01:30 pm ceftazidime - [**2111-3-19**] 04:00 pm infusions: heparin sodium - 600 units/hour other icu medications: furosemide (lasix) - [**2111-3-19**] 11:30 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2111-3-20**] 06:11 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 38.1 c (100.6 tcurrent: 36.9 c (98.5 hr: 95 (88 - 114) bpm bp: 128/82(94) {111/60(74) - 149/84(97)} mmhg rr: 23 (13 - 33) insp/min spo2: 96% heart rhythm: af (atrial fibrillation) wgt (current): 73.4 kg (admission): 73.4 kg height: 68 inch pap: (19 mmhg) / (12 mmhg) total in: 1,657 ml 137 ml po: 660 ml tf: ivf: 997 ml 137 ml blood products: total out: 2,595 ml 555 ml urine: 2,145 ml 555 ml ng: stool: drains: balance: -938 ml -418 ml respiratory support o2 delivery device: nasal cannula spo2: 96% abg: ///25/ physical examination general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no elevation of jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rhonchi heard in [**doctor last name **] segment, no crackles or wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. left upper extremity hematoma. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ labs / radiology 103 k/ul 12.1 g/dl 212 mg/dl 1.4 mg/dl 25 meq/l 9.0 meq/l 52 mg/dl 94 meq/l 128 meq/l 35.8 % 7.8 k/ul [image002.jpg] [**2111-3-16**] 08:39 pm [**2111-3-17**] 03:41 am [**2111-3-17**] 05:49 pm [**2111-3-18**] 03:06 am [**2111-3-18**] 12:00 pm [**2111-3-18**] 05:00 pm [**2111-3-19**] 04:31 am [**2111-3-19**] 05:20 pm [**2111-3-20**] 04:26 am wbc 8.2 8.2 8.1 9.9 7.8 hct 42.6 43.3 37.7 41.7 35.8 plt 99 109 104 117 103 cr 1.6 1.6 1.6 1.5 1.3 1.4 1.4 tropt 3.34 3.87 glucose 296 206 219 178 255 233 246 212 other labs: pt / ptt / inr:16.0/60.9/1.4, ck / ckmb / troponin-t:1046/31/3.87, alt / ast:109/230, alk phos / t bili:97/1.2, differential-neuts:73.3 %, lymph:19.6 %, mono:5.6 %, eos:0.0 %, ca++:8.4 mg/dl, mg++:2.6 mg/dl, po4:3.3 mg/dl assessment and plan 78 yo male with a history of cad, s/p cabg [**39**] years ago, a fib, htn, dm type 2, transferred for treatment of nstemi and a fib with rvr. # nstemi: cath showed 3vd with occlusion of lad (80%) lcx and rca as well as svg. - cabg next week - continue high dose aspirin - considers starting on statin if transaminitis is better - no plavix - continue beta blockers . # systolic heart failure: ef documented to be 20-25% at osh with severe global hypokinesis. likely worsening ef secondary to large nstemi. new flush edema yesterday. - lasix boluse daily for diuresis, goal -1 lt today - monitor electrolytes [**hospital1 **] - tte showed ef 20-25% (same as osh) with severe systolic and diastolic dysfunction, moderate rv hypokinesis. - unable to give ace-i given adverse reaction . # atrial fibrillation: patient is better rate controlled currently. the patient had a run of possible a fib with aberrancy vs. v tach at osh, likely caused by nstemi. - continue metoprolol tartrate 75mg po qid for rapid a fib, consider increasing to 100 mg qid. - monitor on telemetry - on heparin gtt , transition to warfarin post cabg . # pneumonia: possibly hospital acquired pneumonia given recent hospitalization last week for 'weakness.' pt continues to spike temps overnight up to 102.1 yesterday - will continue levaquin started [**2111-3-15**], and vancomycin and ceftaz started [**2111-3-16**] to cover hap . # type 2 dm: - hold home glyburide - sliding scale insulin # transaminitis: likely secondary to low cardiac output in the setting of a large nstemi, or relative hypotension. improving. - continue to trend lfts (trending down over last few days) - hold statins for now # acute on chronic renal insuficiency: at osh, crn on presentation 1.2, with diuresis increased to 1.5. this could also be secondary to low output state. - continue to trend with diuresis # chronic thrombocytopenia: - monitor closely with heparin iv icu care nutrition: glycemic control: lines: 20 gauge - [**2111-3-19**] 05:00 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",1
386,"chief complaint: 24 hour events: - changed to coreg 3.125 and d/c'd dilt gtt. hrs up to 120s-130s. gave another 3.125 coreg without effect (except bp down to 90s/50s). switched back to lopressor 50mg but increased to tid. then increased again to 75mg tid. hrs 90s overnight. bps 120s. - negative 300 at 3pm so did not get extra lasix (goal even) - inr 3 so gave another 5mg po vit k - called id for abx approval but did not get call back pt feels ok this am allergies: penicillins rash; last dose of antibiotics: vancomycin - [**2111-3-17**] 01:33 pm ceftazidime - [**2111-3-18**] 02:00 am infusions: other icu medications: other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2111-3-18**] 06:20 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 38.9 c (102.1 tcurrent: 37.6 c (99.7 hr: 92 (75 - 138) bpm bp: 109/65(73) {90/50(62) - 129/160(98)} mmhg rr: 23 (18 - 32) insp/min spo2: 92% heart rhythm: af (atrial fibrillation) wgt (current): 73.4 kg (admission): 73.4 kg height: 68 inch total in: 1,176 ml 290 ml po: 750 ml 240 ml tf: ivf: 426 ml 50 ml blood products: total out: 1,485 ml 175 ml urine: 1,485 ml 175 ml ng: stool: drains: balance: -309 ml 115 ml respiratory support o2 delivery device: nasal cannula spo2: 92% abg: ///26/ physical examination general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no elevation of jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rhonchi heard in [**doctor last name **] segment, no crackles or wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. left upper extremity hematoma. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ labs / radiology 104 k/ul 13.2 g/dl 219 mg/dl 1.5 mg/dl 26 meq/l 4.9 meq/l 51 mg/dl 99 meq/l 134 meq/l 37.7 % 8.1 k/ul [image002.jpg] [**2111-3-16**] 08:39 pm [**2111-3-17**] 03:41 am [**2111-3-17**] 05:49 pm [**2111-3-18**] 03:06 am wbc 8.2 8.2 8.1 hct 42.6 43.3 37.7 plt 99 109 104 cr 1.6 1.6 1.6 1.5 tropt 3.34 3.87 glucose 296 206 219 other labs: pt / ptt / inr:21.0/41.8/2.0, ck / ckmb / troponin-t:1046/31/3.87, alt / ast:157/416, alk phos / t bili:97/1.2, differential-neuts:73.3 %, lymph:19.6 %, mono:5.6 %, eos:0.0 %, ca++:8.3 mg/dl, mg++:2.4 mg/dl, po4:2.7 mg/dl imaging: tte: the left atrium is normal in size. the estimated right atrial pressure is 10-20mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is severely depressed (lvef= 20-25 %). the estimated cardiac index is depressed (<2.0l/min/m2). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). transmitral doppler and tissue velocity imaging are consistent with grade iii/iv (severe) lv diastolic dysfunction. right ventricular chamber size is normal. with moderate global free wall hypokinesis. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the aortic valve leaflets are moderately thickened. trace aortic regurgitation is seen. there may be aortic stenosis with restricted leaflet opening but the overall transvalvular velocity is preserved (which may be secondary to poor ventricular contractile function). the mitral valve leaflets are mildly thickened. mild to moderate ([**12-5**]+) mitral regurgitation is seen. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. there is (at least) mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. . impression: severe left ventricular systolic and diastolic dysfunction. moderate right ventricular hypokinesis. elevated estimated left ventricular filling pressures. mild to moderate mitral regurgitation. at least mild pulmonary hypertension. thoracic aortic dilation. assessment and plan 78 yo male with a history of cad, s/p cabg [**39**] years ago, a fib, htn, dm type 2, transferred for treatment of nstemi and a fib with rvr. # nstemi: the patient has 38 year old bypass grafts, with no more recent interventions. in the setting of type 2 dm, the likelihood that these grafts have restenosed is very high. most likely the stress of having a pneumonia with a fib precipitated this event. - discontinued heparin drip given supratherapeutic inr - continue plavix 75mg daily (s/p 600mg loading at osh) - continue high dose aspirin - hold high dose statin given transaminitis - continue beta blockers - hold ace-i given his acute on chronic renal failure and adverse reaction to lisinopril (hyperkalemia) - pt may undergo cardiac cath today given inr 2.0 today . # systolic heart failure: ef documented to be 20-25% at osh with severe global hypokinesis. likely worsening ef secondary to large nstemi. - lasix boluses for diuresis, goal to remain even throughout the day - monitor electrolytes [**hospital1 **] - tte yesterday showed ef 20-25% (same as osh) with severe systolic and diastolic dysfunction, moderate rv hypokinesis. - unable to give ace-i given adverse reaction . # atrial fibrillation: patient is better rate controlled currently. the patient had a run of possible a fib with aberrancy vs. v tach at osh, likely caused by nstemi. - continue metoprolol tartrate 75mg po tid for rapid a fib - monitor on telemetry - hold coumadin for likely cath today . # pneumonia: possibly hospital acquired pneumonia given recent hospitalization last week for 'weakness.' pt continues to spike temps overnight up to 102.1 yesterday - will continue levaquin started [**2111-3-15**], and vancomycin and ceftaz started [**2111-3-16**] to cover hap . # type 2 dm: - hold home glyburide - sliding scale insulin . # hypertension: - will use metoprolol instead of home propranolol in the attempt to rate control - will restart home amlodipine as needed . # transaminitis: likely secondary to low cardiac output in the setting of a large nstemi, or relative hypotension. at osh, t bili 2.6, direct 0.6, ast 288, alt 170, ap 106. trending up ast now 458, inr 3.9 - continue to trend lfts - hold statins for now . # acute on chronic renal insuficiency: at osh, crn on presentation 1.2, with diuresis increased to 1.5. this could also be secondary to low output state. - continue to trend with diuresis . # chronic thrombocytopenia: - monitor closely with heparin iv . icu care nutrition: npo as may go to cath lab today glycemic control: lines: 22 gauge - [**2111-3-16**] 07:00 pm 20 gauge - [**2111-3-16**] 07:00 pm prophylaxis: dvt therapeutic inr stress ulcer: vap: comments: communication: comments: code status: full code disposition: ccu",1
387,"chief complaint: 24 hour events: - changed to coreg 3.125 and d/c'd dilt gtt. hrs up to 120s-130s. gave another 3.125 coreg without effect (except bp down to 90s/50s). switched back to lopressor 50mg but increased to tid. then increased again to 75mg tid. hrs 90s overnight. bps 120s. - negative 300 at 3pm so did not get extra lasix (goal even) - inr 3 so gave another 5mg po vit k - called id for abx approval but did not get call back pt feels ok this am allergies: penicillins rash; last dose of antibiotics: vancomycin - [**2111-3-17**] 01:33 pm ceftazidime - [**2111-3-18**] 02:00 am infusions: other icu medications: other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2111-3-18**] 06:20 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 38.9 c (102.1 tcurrent: 37.6 c (99.7 hr: 92 (75 - 138) bpm bp: 109/65(73) {90/50(62) - 129/160(98)} mmhg rr: 23 (18 - 32) insp/min spo2: 92% heart rhythm: af (atrial fibrillation) wgt (current): 73.4 kg (admission): 73.4 kg height: 68 inch total in: 1,176 ml 290 ml po: 750 ml 240 ml tf: ivf: 426 ml 50 ml blood products: total out: 1,485 ml 175 ml urine: 1,485 ml 175 ml ng: stool: drains: balance: -309 ml 115 ml respiratory support o2 delivery device: nasal cannula spo2: 92% abg: ///26/ physical examination general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no elevation of jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rhonchi heard in [**doctor last name **] segment, no crackles or wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. left upper extremity hematoma. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ labs / radiology 104 k/ul 13.2 g/dl 219 mg/dl 1.5 mg/dl 26 meq/l 4.9 meq/l 51 mg/dl 99 meq/l 134 meq/l 37.7 % 8.1 k/ul [image002.jpg] [**2111-3-16**] 08:39 pm [**2111-3-17**] 03:41 am [**2111-3-17**] 05:49 pm [**2111-3-18**] 03:06 am wbc 8.2 8.2 8.1 hct 42.6 43.3 37.7 plt 99 109 104 cr 1.6 1.6 1.6 1.5 tropt 3.34 3.87 glucose 296 206 219 other labs: pt / ptt / inr:21.0/41.8/2.0, ck / ckmb / troponin-t:1046/31/3.87, alt / ast:157/416, alk phos / t bili:97/1.2, differential-neuts:73.3 %, lymph:19.6 %, mono:5.6 %, eos:0.0 %, ca++:8.3 mg/dl, mg++:2.4 mg/dl, po4:2.7 mg/dl imaging: tte: the left atrium is normal in size. the estimated right atrial pressure is 10-20mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is severely depressed (lvef= 20-25 %). the estimated cardiac index is depressed (<2.0l/min/m2). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). transmitral doppler and tissue velocity imaging are consistent with grade iii/iv (severe) lv diastolic dysfunction. right ventricular chamber size is normal. with moderate global free wall hypokinesis. the aortic root is mildly dilated at the sinus level. the ascending aorta is mildly dilated. the aortic valve leaflets are moderately thickened. trace aortic regurgitation is seen. there may be aortic stenosis with restricted leaflet opening but the overall transvalvular velocity is preserved (which may be secondary to poor ventricular contractile function). the mitral valve leaflets are mildly thickened. mild to moderate ([**12-5**]+) mitral regurgitation is seen. the left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. there is (at least) mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. . impression: severe left ventricular systolic and diastolic dysfunction. moderate right ventricular hypokinesis. elevated estimated left ventricular filling pressures. mild to moderate mitral regurgitation. at least mild pulmonary hypertension. thoracic aortic dilation. assessment and plan 78 yo male with a history of cad, s/p cabg [**39**] years ago, a fib, htn, dm type 2, transferred for treatment of nstemi and a fib with rvr. # nstemi: the patient has 38 year old bypass grafts, with no more recent interventions. in the setting of type 2 dm, the likelihood that these grafts have restenosed is very high. most likely the stress of having a pneumonia with a fib precipitated this event. - discontinued heparin drip given supratherapeutic inr - continue plavix 75mg daily (s/p 600mg loading at osh) - continue high dose aspirin - hold high dose statin given transaminitis - continue beta blockers - hold ace-i given his acute on chronic renal failure and adverse reaction to lisinopril (hyperkalemia) - pt may undergo cardiac cath today given inr 2.0 today . # systolic heart failure: ef documented to be 20-25% at osh with severe global hypokinesis. likely worsening ef secondary to large nstemi. - lasix boluses for diuresis, goal to remain even throughout the day - monitor electrolytes [**hospital1 **] - tte yesterday showed ef 20-25% (same as osh) with severe systolic and diastolic dysfunction, moderate rv hypokinesis. - unable to give ace-i given adverse reaction . # atrial fibrillation: patient is better rate controlled currently. the patient had a run of possible a fib with aberrancy vs. v tach at osh, likely caused by nstemi. - continue metoprolol tartrate 75mg po tid for rapid a fib - monitor on telemetry - hold coumadin for likely cath today and restart heparin gtt for prophylaxis . # pneumonia: possibly hospital acquired pneumonia given recent hospitalization last week for 'weakness.' pt continues to spike temps overnight up to 102.1 yesterday - will continue levaquin started [**2111-3-15**], and vancomycin and ceftaz started [**2111-3-16**] to cover hap . # type 2 dm: - hold home glyburide - sliding scale insulin . # hypertension: - will use metoprolol instead of home propranolol in the attempt to rate control - will restart home amlodipine as needed . # transaminitis: likely secondary to low cardiac output in the setting of a large nstemi, or relative hypotension. at osh, t bili 2.6, direct 0.6, ast 288, alt 170, ap 106. trending up ast now 458, inr 3.9 - continue to trend lfts - hold statins for now . # acute on chronic renal insuficiency: at osh, crn on presentation 1.2, with diuresis increased to 1.5. this could also be secondary to low output state. - continue to trend with diuresis . # chronic thrombocytopenia: - monitor closely with heparin iv . icu care nutrition: npo as may go to cath lab today glycemic control: lines: 22 gauge - [**2111-3-16**] 07:00 pm 20 gauge - [**2111-3-16**] 07:00 pm prophylaxis: dvt therapeutic inr restart hep gtt today stress ulcer: vap: comments: communication: comments: code status: full code disposition: ccu",1
388,"chief complaint: 24 hour events: cardiac cath - at [**2111-3-19**] 09:30 am arterial line - start [**2111-3-19**] 01:00 pm pa catheter - start [**2111-3-19**] 01:24 pm pa catheter - stop [**2111-3-19**] 02:35 pm arterial line - stop [**2111-3-19**] 02:35 pm [**2111-3-19**]: - cath this am: showed 3vd and stenosed venous grafts, pt will need revision cabg. ct [**doctor first name 91**] consulted. plan for revision cabg on tuesday panorex ordered, call dental consult in am [**numeric identifier 5809**], ct chest and carotids ordered, - pt received iv lasix during cath for pulmonary edema - pa pressures low, added 50cc/hr of ns - bg running high, likely secondary to stress and infection, increased sliding scale by 2 units - restarted heparin at 7:30pm allergies: penicillins rash; last dose of antibiotics: levofloxacin - [**2111-3-18**] 10:00 am vancomycin - [**2111-3-19**] 01:30 pm ceftazidime - [**2111-3-19**] 04:00 pm infusions: heparin sodium - 600 units/hour other icu medications: furosemide (lasix) - [**2111-3-19**] 11:30 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2111-3-20**] 06:11 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 38.1 c (100.6 tcurrent: 36.9 c (98.5 hr: 95 (88 - 114) bpm bp: 128/82(94) {111/60(74) - 149/84(97)} mmhg rr: 23 (13 - 33) insp/min spo2: 96% heart rhythm: af (atrial fibrillation) wgt (current): 73.4 kg (admission): 73.4 kg height: 68 inch pap: (19 mmhg) / (12 mmhg) total in: 1,657 ml 137 ml po: 660 ml tf: ivf: 997 ml 137 ml blood products: total out: 2,595 ml 555 ml urine: 2,145 ml 555 ml ng: stool: drains: balance: -938 ml -418 ml respiratory support o2 delivery device: nasal cannula spo2: 96% abg: ///25/ physical examination general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no elevation of jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rhonchi heard in [**doctor last name **] segment, no crackles or wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. left upper extremity hematoma. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ labs / radiology 103 k/ul 12.1 g/dl 212 mg/dl 1.4 mg/dl 25 meq/l 9.0 meq/l 52 mg/dl 94 meq/l 128 meq/l 35.8 % 7.8 k/ul [image002.jpg] [**2111-3-16**] 08:39 pm [**2111-3-17**] 03:41 am [**2111-3-17**] 05:49 pm [**2111-3-18**] 03:06 am [**2111-3-18**] 12:00 pm [**2111-3-18**] 05:00 pm [**2111-3-19**] 04:31 am [**2111-3-19**] 05:20 pm [**2111-3-20**] 04:26 am wbc 8.2 8.2 8.1 9.9 7.8 hct 42.6 43.3 37.7 41.7 35.8 plt 99 109 104 117 103 cr 1.6 1.6 1.6 1.5 1.3 1.4 1.4 tropt 3.34 3.87 glucose 296 206 219 178 255 233 246 212 other labs: pt / ptt / inr:16.0/60.9/1.4, ck / ckmb / troponin-t:1046/31/3.87, alt / ast:109/230, alk phos / t bili:97/1.2, differential-neuts:73.3 %, lymph:19.6 %, mono:5.6 %, eos:0.0 %, ca++:8.4 mg/dl, mg++:2.6 mg/dl, po4:3.3 mg/dl assessment and plan 78 yo male with a history of cad, s/p cabg [**39**] years ago, a fib, htn, dm type 2, transferred for treatment of nstemi and a fib with rvr. # nstemi: the patient has 38 year old bypass grafts, with no more recent interventions. in the setting of type 2 dm, the likelihood that these grafts have restenosed is very high. most likely the stress of having a pneumonia with a fib precipitated this event. - cath today - continue plavix 75mg daily (s/p 600mg loading at osh) - continue high dose aspirin - hold high dose statin given transaminitis - continue beta blockers . # systolic heart failure: ef documented to be 20-25% at osh with severe global hypokinesis. likely worsening ef secondary to large nstemi. new flush edema, likely [**1-5**] to not taking daily lasix. - lasix boluse daily for diuresis, goal -2 lt today - monitor electrolytes [**hospital1 **] - tte showed ef 20-25% (same as osh) with severe systolic and diastolic dysfunction, moderate rv hypokinesis. - unable to give ace-i given adverse reaction . # atrial fibrillation: patient is better rate controlled currently. the patient had a run of possible a fib with aberrancy vs. v tach at osh, likely caused by nstemi. - continue metoprolol tartrate 75mg po qid for rapid a fib, consider increasing to 100 mg qid. - monitor on telemetry - hold coumadin for likely cath today and restart heparin gtt for prophylaxis . # pneumonia: possibly hospital acquired pneumonia given recent hospitalization last week for 'weakness.' pt continues to spike temps overnight up to 102.1 yesterday - will continue levaquin started [**2111-3-15**], and vancomycin and ceftaz started [**2111-3-16**] to cover hap . # type 2 dm: - hold home glyburide - sliding scale insulin . # hypertension: - will use metoprolol instead of home propranolol in the attempt to rate control - will restart home amlodipine as needed . # transaminitis: likely secondary to low cardiac output in the setting of a large nstemi, or relative hypotension. at osh, t bili 2.6, direct 0.6, ast 288, alt 170, ap 106. trending up ast now 458, inr 3.9 - continue to trend lfts (trending down over last few days) - hold statins for now . # acute on chronic renal insuficiency: at osh, crn on presentation 1.2, with diuresis increased to 1.5. this could also be secondary to low output state. - continue to trend with diuresis . # chronic thrombocytopenia: - monitor closely with heparin iv icu care nutrition: glycemic control: lines: 20 gauge - [**2111-3-19**] 05:00 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",1
389,"chief complaint: 24 hour events: blood cultured - at [**2111-3-16**] 08:30 pm nasal swab - at [**2111-3-17**] 01:00 am [**2111-3-16**]: - gave additional dose of lopressor 5mg iv for rapid a fib - replaced k - ast elevated to 458 - cxr shows bl infiltrate worse on left upper - gave one dose of zyprexa for agitation - increased metoprolol to 50mg [**hospital1 **] - gave 5mg of vit k given for inr 3.9 - atrovent inhaler and gave extra dose of lasix 20mg iv for wheezing - attempted rate control with iv dilt 10mg x2 as rate persistently in the 110's, somewhat better control, down to 90's, so started dilt drip overnight, with not much effect . allergies: penicillins rash; last dose of antibiotics: infusions: diltiazem - 15 mg/hour heparin sodium - 600 units/hour other icu medications: metoprolol - [**2111-3-16**] 09:50 pm furosemide (lasix) - [**2111-3-17**] 12:50 am diltiazem - [**2111-3-17**] 01:15 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2111-3-17**] 06:21 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.3 c (99.2 tcurrent: 37.1 c (98.8 hr: 108 (97 - 117) bpm bp: 142/62(79) {109/58(70) - 150/101(104)} mmhg rr: 30 (23 - 31) insp/min spo2: 95% heart rhythm: af (atrial fibrillation) height: 68 inch total in: 359 ml 201 ml po: 330 ml 90 ml tf: ivf: 29 ml 111 ml blood products: total out: 885 ml 695 ml urine: 885 ml 695 ml ng: stool: drains: balance: -526 ml -494 ml respiratory support o2 delivery device: nasal cannula spo2: 95% abg: ///28/ physical examination general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no elevation of jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rhonchi heard in [**doctor last name **] segment, no crackles or wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. left upper extremity hematoma. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ labs / radiology 109 k/ul 14.9 g/dl 206 mg/dl 1.6 mg/dl 28 meq/l 3.5 meq/l 40 mg/dl 94 meq/l 134 meq/l 43.3 % 8.2 k/ul [image002.jpg] [**2111-3-16**] 08:39 pm [**2111-3-17**] 03:41 am wbc 8.2 8.2 hct 42.6 43.3 plt 99 109 cr 1.6 1.6 tropt 3.34 3.87 glucose 296 206 other labs: pt / ptt / inr:40.6/119.9/4.4, ck / ckmb / troponin-t:1046/31/3.87, alt / ast:165/458, alk phos / t bili:101/1.4, differential-neuts:73.3 %, lymph:19.6 %, mono:5.6 %, eos:0.0 %, ca++:9.1 mg/dl, mg++:2.2 mg/dl, po4:1.8 mg/dl assessment and plan 78 yo male with a history of cad, s/p cabg [**39**] years ago, a fib, htn, dm type 2, transferred for treatment of nstemi and a fib with rvr. # nstemi: the patient has 38 year old bypass grafts, with no more recent interventions. in the setting of type 2 dm, the likelihood that these grafts have restenosed is very high. most likely the stress of having a pneumonia with a fib precipitated this event. - restart heparin drip - continue plavix 75mg daily (s/p 600mg loading at osh) - continue high dose aspirin - hold high dose statin given transaminitis - continue beta blockers - hold ace-i given his acute on chronic renal failure and adverse reaction to lisinopril (hyperkalemia) - plan for cardiac cath when inr less, however trending up, gave vit k yesterday - trend ce's until peak - ekg in am . # systolic heart failure: ef documented to be 20-25% at osh with severe global hypokinesis. likely worsening ef secondary to large nstemi. - lasix boluses for diuresis, goal uop 100cc/hr - monitor electrolytes [**hospital1 **] - tte today to evaluate for fixed wall motion abnormalities and ef - unable to give ace-i given adverse reaction . # atrial fibrillation: patient is in rapid ventricular rate currently. the patient had a run of possible a fib with aberrancy vs. v tach earlier today at osh, likely caused by nstemi. - continue metoprolol tartrate 50mg po bid - continue diltiazem drip - monitor on telemetry - hold coumadin, continue heparin drip for now . # pneumonia: possibly hospital acquired pneumonia given recent hospitalization last week for 'weakness.' - cxr on admission - will continue levaquin started [**2111-3-15**] - will add vancomycin and ceftaz to cover hap . # type 2 dm: - hold home glyburide - sliding scale insulin . # hypertension: - will use metoprolol instead of home propranolol in the attempt to rate control - will restart home amlodipine as needed . # transaminitis: likely secondary to low cardiac output in the setting of a large nstemi, or relative hypotension. at osh, t bili 2.6, direct 0.6, ast 288, alt 170, ap 106. trending up ast now 458, inr 3.9 - continue to trend lfts - hold statins for now . # acute on chronic renal insuficiency: at osh, crn on presentation 1.2, with diuresis increased to 1.5. this could also be secondary to low output state. - continue to trend with diuresis . # chronic thrombocytopenia: - monitor closely with heparin iv . icu care nutrition: npo as may go to cath lab today glycemic control: lines: 22 gauge - [**2111-3-16**] 07:00 pm 20 gauge - [**2111-3-16**] 07:00 pm prophylaxis: dvt: heparin drip stress ulcer: vap: comments: communication: comments: code status: full code disposition: ccu ------ protected section ------ i reviewed overnight course.examined pt. i agree with dr.[**last name (stitle) **] s notes and plan of treatment. since he is stable we can wait bfor inr ,1.5 for cath. [**month (only) 8**] need vit k. [**first name4 (namepattern1) **] [**last name (namepattern1) **] ------ protected section addendum entered by:[**name (ni) **] [**name (ni) 4425**] on:[**2111-3-17**] 19:00 ------",1
390,"chief complaint: 24 hour events: blood cultured - at [**2111-3-16**] 08:30 pm nasal swab - at [**2111-3-17**] 01:00 am [**2111-3-16**]: - gave additional dose of lopressor 5mg iv for rapid a fib - replaced k - ast elevated to 458 - cxr shows bl infiltrate worse on left upper - gave one dose of zyprexa for agitation - increased metoprolol to 50mg [**hospital1 **] - gave 5mg of vit k given for inr 3.9 - atrovent inhaler and gave extra dose of lasix 20mg iv for wheezing - attempted rate control with iv dilt 10mg x2 as rate persistently in the 110's, somewhat better control, down to 90's, so started dilt drip overnight, with not much effect . allergies: penicillins rash; last dose of antibiotics: infusions: diltiazem - 15 mg/hour heparin sodium - 600 units/hour other icu medications: metoprolol - [**2111-3-16**] 09:50 pm furosemide (lasix) - [**2111-3-17**] 12:50 am diltiazem - [**2111-3-17**] 01:15 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2111-3-17**] 06:21 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.3 c (99.2 tcurrent: 37.1 c (98.8 hr: 108 (97 - 117) bpm bp: 142/62(79) {109/58(70) - 150/101(104)} mmhg rr: 30 (23 - 31) insp/min spo2: 95% heart rhythm: af (atrial fibrillation) height: 68 inch total in: 359 ml 201 ml po: 330 ml 90 ml tf: ivf: 29 ml 111 ml blood products: total out: 885 ml 695 ml urine: 885 ml 695 ml ng: stool: drains: balance: -526 ml -494 ml respiratory support o2 delivery device: nasal cannula spo2: 95% abg: ///28/ physical examination general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no elevation of jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rhonchi heard in [**doctor last name **] segment, no crackles or wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. left upper extremity hematoma. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ labs / radiology 109 k/ul 14.9 g/dl 206 mg/dl 1.6 mg/dl 28 meq/l 3.5 meq/l 40 mg/dl 94 meq/l 134 meq/l 43.3 % 8.2 k/ul [image002.jpg] [**2111-3-16**] 08:39 pm [**2111-3-17**] 03:41 am wbc 8.2 8.2 hct 42.6 43.3 plt 99 109 cr 1.6 1.6 tropt 3.34 3.87 glucose 296 206 other labs: pt / ptt / inr:40.6/119.9/4.4, ck / ckmb / troponin-t:1046/31/3.87, alt / ast:165/458, alk phos / t bili:101/1.4, differential-neuts:73.3 %, lymph:19.6 %, mono:5.6 %, eos:0.0 %, ca++:9.1 mg/dl, mg++:2.2 mg/dl, po4:1.8 mg/dl assessment and plan 78 yo male with a history of cad, s/p cabg [**39**] years ago, a fib, htn, dm type 2, transferred for treatment of nstemi and a fib with rvr. # nstemi: the patient has 38 year old bypass grafts, with no more recent interventions. in the setting of type 2 dm, the likelihood that these grafts have restenosed is very high. most likely the stress of having a pneumonia with a fib precipitated this event. - restart heparin drip - continue plavix 75mg daily (s/p 600mg loading at osh) - continue high dose aspirin - hold high dose statin given transaminitis - continue beta blockers - hold ace-i given his acute on chronic renal failure and adverse reaction to lisinopril (hyperkalemia) - plan for cardiac cath when inr less, however trending up, gave vit k yesterday - trend ce's until peak - ekg in am . # systolic heart failure: ef documented to be 20-25% at osh with severe global hypokinesis. likely worsening ef secondary to large nstemi. - lasix boluses for diuresis, goal uop 100cc/hr - monitor electrolytes [**hospital1 **] - tte today to evaluate for fixed wall motion abnormalities and ef - unable to give ace-i given adverse reaction . # atrial fibrillation: patient is in rapid ventricular rate currently. the patient had a run of possible a fib with aberrancy vs. v tach earlier today at osh, likely caused by nstemi. - continue metoprolol tartrate 50mg po bid - continue diltiazem drip - monitor on telemetry - hold coumadin, continue heparin drip for now . # pneumonia: possibly hospital acquired pneumonia given recent hospitalization last week for 'weakness.' - cxr on admission - will continue levaquin started [**2111-3-15**] - will add vancomycin and ceftaz to cover hap . # type 2 dm: - hold home glyburide - sliding scale insulin . # hypertension: - will use metoprolol instead of home propranolol in the attempt to rate control - will restart home amlodipine as needed . # transaminitis: likely secondary to low cardiac output in the setting of a large nstemi, or relative hypotension. at osh, t bili 2.6, direct 0.6, ast 288, alt 170, ap 106. trending up ast now 458, inr 3.9 - continue to trend lfts - hold statins for now . # acute on chronic renal insuficiency: at osh, crn on presentation 1.2, with diuresis increased to 1.5. this could also be secondary to low output state. - continue to trend with diuresis . # chronic thrombocytopenia: - monitor closely with heparin iv . icu care nutrition: npo as may go to cath lab today glycemic control: lines: 22 gauge - [**2111-3-16**] 07:00 pm 20 gauge - [**2111-3-16**] 07:00 pm prophylaxis: dvt: heparin drip stress ulcer: vap: comments: communication: comments: code status: full code disposition: ccu ------ protected section ------ i reviewed overnight course.examined pt. i agree with dr.[**last name (stitle) **] s notes and plan of treatment. since he is stable we can wait bfor inr ,1.5 for cath. [**month (only) 8**] need vit k. [**first name4 (namepattern1) **] [**last name (namepattern1) **] ------ protected section addendum entered by:[**name (ni) **] [**name (ni) 4425**] on:[**2111-3-17**] 19:00 ------ spent 45 mins on case. [**first name4 (namepattern1) **] [**last name (namepattern1) **] ------ protected section addendum entered by:[**name (ni) **] [**name (ni) 4425**] on:[**2111-3-17**] 19:06 ------",1
391,"chief complaint: 24 hour events: cardiac cath - at [**2111-3-19**] 09:30 am arterial line - start [**2111-3-19**] 01:00 pm pa catheter - start [**2111-3-19**] 01:24 pm pa catheter - stop [**2111-3-19**] 02:35 pm arterial line - stop [**2111-3-19**] 02:35 pm [**2111-3-19**]: - cath this am: showed 3vd and stenosed venous grafts, pt will need revision cabg. ct [**doctor first name 91**] consulted. plan for revision cabg on tuesday panorex ordered, call dental consult in am [**numeric identifier 5809**], ct chest and carotids ordered, - pt received iv lasix during cath for pulmonary edema - pa pressures low, added 50cc/hr of ns - bg running high, likely secondary to stress and infection, increased sliding scale by 2 units - restarted heparin at 7:30pm allergies: penicillins rash; last dose of antibiotics: levofloxacin - [**2111-3-18**] 10:00 am vancomycin - [**2111-3-19**] 01:30 pm ceftazidime - [**2111-3-19**] 04:00 pm infusions: heparin sodium - 600 units/hour other icu medications: furosemide (lasix) - [**2111-3-19**] 11:30 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2111-3-20**] 06:11 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 38.1 c (100.6 tcurrent: 36.9 c (98.5 hr: 95 (88 - 114) bpm bp: 128/82(94) {111/60(74) - 149/84(97)} mmhg rr: 23 (13 - 33) insp/min spo2: 96% heart rhythm: af (atrial fibrillation) wgt (current): 73.4 kg (admission): 73.4 kg height: 68 inch pap: (19 mmhg) / (12 mmhg) total in: 1,657 ml 137 ml po: 660 ml tf: ivf: 997 ml 137 ml blood products: total out: 2,595 ml 555 ml urine: 2,145 ml 555 ml ng: stool: drains: balance: -938 ml -418 ml respiratory support o2 delivery device: nasal cannula spo2: 96% abg: ///25/ physical examination general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no elevation of jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rhonchi heard in [**doctor last name **] segment, no crackles or wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. left upper extremity hematoma. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ labs / radiology 103 k/ul 12.1 g/dl 212 mg/dl 1.4 mg/dl 25 meq/l 9.0 meq/l 52 mg/dl 94 meq/l 128 meq/l 35.8 % 7.8 k/ul [image002.jpg] [**2111-3-16**] 08:39 pm [**2111-3-17**] 03:41 am [**2111-3-17**] 05:49 pm [**2111-3-18**] 03:06 am [**2111-3-18**] 12:00 pm [**2111-3-18**] 05:00 pm [**2111-3-19**] 04:31 am [**2111-3-19**] 05:20 pm [**2111-3-20**] 04:26 am wbc 8.2 8.2 8.1 9.9 7.8 hct 42.6 43.3 37.7 41.7 35.8 plt 99 109 104 117 103 cr 1.6 1.6 1.6 1.5 1.3 1.4 1.4 tropt 3.34 3.87 glucose 296 206 219 178 255 233 246 212 other labs: pt / ptt / inr:16.0/60.9/1.4, ck / ckmb / troponin-t:1046/31/3.87, alt / ast:109/230, alk phos / t bili:97/1.2, differential-neuts:73.3 %, lymph:19.6 %, mono:5.6 %, eos:0.0 %, ca++:8.4 mg/dl, mg++:2.6 mg/dl, po4:3.3 mg/dl assessment and plan 78 yo male with a history of cad, s/p cabg [**39**] years ago, a fib, htn, dm type 2, transferred for treatment of nstemi and a fib with rvr. # nstemi: cath showed 3vd with occlusion of lad (80%) lcx and rca as well as svg. - cabg next week - continue high dose aspirin - considers starting on statin if transaminitis is better - no plavix - continue beta blockers . # systolic heart failure: ef documented to be 20-25% at osh with severe global hypokinesis. likely worsening ef secondary to large nstemi. new flush edema yesterday. - lasix boluse daily for diuresis, goal -1 lt today - monitor electrolytes [**hospital1 **] - tte showed ef 20-25% (same as osh) with severe systolic and diastolic dysfunction, moderate rv hypokinesis. - unable to give ace-i given adverse reaction . # atrial fibrillation: patient is better rate controlled currently. the patient had a run of possible a fib with aberrancy vs. v tach at osh, likely caused by nstemi. - continue metoprolol tartrate 75mg po qid for rapid a fib, consider increasing to 100 mg qid. - monitor on telemetry - on heparin gtt , transition to warfarin post cabg . # pneumonia: possibly hospital acquired pneumonia given recent hospitalization last week for 'weakness.' pt continues to spike temps overnight up to 102.1 yesterday - will continue levaquin started [**2111-3-15**], and vancomycin and ceftaz started [**2111-3-16**] to cover hap . # type 2 dm: - hold home glyburide - sliding scale insulin # transaminitis: likely secondary to low cardiac output in the setting of a large nstemi, or relative hypotension. improving. - continue to trend lfts (trending down over last few days) - hold statins for now # acute on chronic renal insuficiency: at osh, crn on presentation 1.2, with diuresis increased to 1.5. this could also be secondary to low output state. - continue to trend with diuresis # chronic thrombocytopenia: - monitor closely with heparin iv icu care nutrition: glycemic control: lines: 20 gauge - [**2111-3-19**] 05:00 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition: ------ protected section ------ much better this am.pneumonia clearing.i examined pt and agree with dr.[**last name (stitle) **] s note. spent 35mins on case.frr cabg next week.needs prop testing. [**first name4 (namepattern1) **] [**last name (namepattern1) 4425**] ------ protected section addendum entered by:[**name (ni) **] [**name (ni) 4425**] on:[**2111-3-20**] 11:54 ------",1
392,"chief complaint: 24 hour events: - intermittent arvr, increased po metoprolol to 75 - on the schedule for cath in am - cxr: edema is better - this am, +sob/crackles on exam, 40 iv lasix, 2 mg iv morphine, 5 mg iv metoprolol, cxr (bp 90s so did not give nitro yet) allergies: penicillins rash; last dose of antibiotics: levofloxacin - [**2111-3-18**] 10:00 am vancomycin - [**2111-3-18**] 12:00 pm ceftazidime - [**2111-3-18**] 03:30 pm infusions: heparin sodium - 600 units/hour other icu medications: metoprolol - [**2111-3-19**] 03:47 am furosemide (lasix) - [**2111-3-19**] 05:15 am morphine sulfate - [**2111-3-19**] 05:15 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2111-3-19**] 05:29 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.8 c (100.1 tcurrent: 37.2 c (98.9 hr: 109 (88 - 144) bpm bp: 90/71(74) {90/57(71) - 144/101(107)} mmhg rr: 26 (17 - 31) insp/min spo2: 98% heart rhythm: af (atrial fibrillation) wgt (current): 73.4 kg (admission): 73.4 kg height: 68 inch total in: 1,223 ml 33 ml po: 840 ml tf: ivf: 383 ml 33 ml blood products: total out: 1,235 ml 280 ml urine: 1,235 ml 280 ml ng: stool: drains: balance: -12 ml -247 ml respiratory support o2 delivery device: high flow neb spo2: 98% abg: //// physical examination general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no elevation of jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rhonchi heard in [**doctor last name **] segment, no crackles or wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. left upper extremity hematoma. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ labs / radiology 117 k/ul 14.1 g/dl 255 1.5 mg/dl 26 meq/l 4.9 meq/l 51 mg/dl 99 meq/l 134 meq/l 41.7 % 9.9 k/ul [image002.jpg] [**2111-3-16**] 08:39 pm [**2111-3-17**] 03:41 am [**2111-3-17**] 05:49 pm [**2111-3-18**] 03:06 am [**2111-3-18**] 12:00 pm [**2111-3-18**] 05:00 pm [**2111-3-19**] 04:31 am wbc 8.2 8.2 8.1 9.9 hct 42.6 43.3 37.7 41.7 plt 99 109 104 117 cr 1.6 1.6 1.6 1.5 tropt 3.34 3.87 glucose 296 206 219 178 255 other labs: pt / ptt / inr:21.0/68.5/2.0, ck / ckmb / troponin-t:1046/31/3.87, alt / ast:109/230, alk phos / t bili:97/1.2, differential-neuts:73.3 %, lymph:19.6 %, mono:5.6 %, eos:0.0 %, ca++:8.3 mg/dl, mg++:2.4 mg/dl, po4:2.7 mg/dl assessment and plan 78 yo male with a history of cad, s/p cabg [**39**] years ago, a fib, htn, dm type 2, transferred for treatment of nstemi and a fib with rvr. # nstemi: the patient has 38 year old bypass grafts, with no more recent interventions. in the setting of type 2 dm, the likelihood that these grafts have restenosed is very high. most likely the stress of having a pneumonia with a fib precipitated this event. - cath today - continue plavix 75mg daily (s/p 600mg loading at osh) - continue high dose aspirin - hold high dose statin given transaminitis - continue beta blockers . # systolic heart failure: ef documented to be 20-25% at osh with severe global hypokinesis. likely worsening ef secondary to large nstemi. new flush edema, likely [**1-5**] to not taking daily lasix. - lasix boluse daily for diuresis, goal -2 lt today - monitor electrolytes [**hospital1 **] - tte showed ef 20-25% (same as osh) with severe systolic and diastolic dysfunction, moderate rv hypokinesis. - unable to give ace-i given adverse reaction . # atrial fibrillation: patient is better rate controlled currently. the patient had a run of possible a fib with aberrancy vs. v tach at osh, likely caused by nstemi. - continue metoprolol tartrate 75mg po qid for rapid a fib, consider increasing to 100 mg qid. - monitor on telemetry - hold coumadin for likely cath today and restart heparin gtt for prophylaxis . # pneumonia: possibly hospital acquired pneumonia given recent hospitalization last week for 'weakness.' pt continues to spike temps overnight up to 102.1 yesterday - will continue levaquin started [**2111-3-15**], and vancomycin and ceftaz started [**2111-3-16**] to cover hap . # type 2 dm: - hold home glyburide - sliding scale insulin . # hypertension: - will use metoprolol instead of home propranolol in the attempt to rate control - will restart home amlodipine as needed . # transaminitis: likely secondary to low cardiac output in the setting of a large nstemi, or relative hypotension. at osh, t bili 2.6, direct 0.6, ast 288, alt 170, ap 106. trending up ast now 458, inr 3.9 - continue to trend lfts (trending down over last few days) - hold statins for now . # acute on chronic renal insuficiency: at osh, crn on presentation 1.2, with diuresis increased to 1.5. this could also be secondary to low output state. - continue to trend with diuresis . # chronic thrombocytopenia: - monitor closely with heparin iv icu care nutrition: npo currently for cath glycemic control: iss lines: 22 gauge - [**2111-3-16**] 07:00 pm 20 gauge - [**2111-3-16**] 07:00 pm prophylaxis: dvt: hep gtt stress ulcer: po diet communication: with patient and family code status: full disposition: to cath today",1
393,"chief complaint: 24 hour events: cardiac cath - at [**2111-3-19**] 09:30 am arterial line - start [**2111-3-19**] 01:00 pm pa catheter - start [**2111-3-19**] 01:24 pm pa catheter - stop [**2111-3-19**] 02:35 pm arterial line - stop [**2111-3-19**] 02:35 pm [**2111-3-19**]: - cath this am: showed 3vd and stenosed venous grafts, pt will need revision cabg. ct [**doctor first name 91**] consulted. plan for revision cabg on tuesday panorex ordered, call dental consult in am [**numeric identifier 5809**], ct chest and carotids ordered, - pt received iv lasix during cath for pulmonary edema - pa pressures low, added 50cc/hr of ns - bg running high, likely secondary to stress and infection, increased sliding scale by 2 units - restarted heparin at 7:30pm allergies: penicillins rash; last dose of antibiotics: levofloxacin - [**2111-3-18**] 10:00 am vancomycin - [**2111-3-19**] 01:30 pm ceftazidime - [**2111-3-19**] 04:00 pm infusions: heparin sodium - 600 units/hour other icu medications: furosemide (lasix) - [**2111-3-19**] 11:30 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2111-3-20**] 06:11 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 38.1 c (100.6 tcurrent: 36.9 c (98.5 hr: 95 (88 - 114) bpm bp: 128/82(94) {111/60(74) - 149/84(97)} mmhg rr: 23 (13 - 33) insp/min spo2: 96% heart rhythm: af (atrial fibrillation) wgt (current): 73.4 kg (admission): 73.4 kg height: 68 inch pap: (19 mmhg) / (12 mmhg) total in: 1,657 ml 137 ml po: 660 ml tf: ivf: 997 ml 137 ml blood products: total out: 2,595 ml 555 ml urine: 2,145 ml 555 ml ng: stool: drains: balance: -938 ml -418 ml respiratory support o2 delivery device: nasal cannula spo2: 96% abg: ///25/ physical examination general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no elevation of jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rhonchi heard in [**doctor last name **] segment, no crackles or wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. left upper extremity hematoma. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ labs / radiology 103 k/ul 12.1 g/dl 212 mg/dl 1.4 mg/dl 25 meq/l 9.0 meq/l 52 mg/dl 94 meq/l 128 meq/l 35.8 % 7.8 k/ul [image002.jpg] [**2111-3-16**] 08:39 pm [**2111-3-17**] 03:41 am [**2111-3-17**] 05:49 pm [**2111-3-18**] 03:06 am [**2111-3-18**] 12:00 pm [**2111-3-18**] 05:00 pm [**2111-3-19**] 04:31 am [**2111-3-19**] 05:20 pm [**2111-3-20**] 04:26 am wbc 8.2 8.2 8.1 9.9 7.8 hct 42.6 43.3 37.7 41.7 35.8 plt 99 109 104 117 103 cr 1.6 1.6 1.6 1.5 1.3 1.4 1.4 tropt 3.34 3.87 glucose 296 206 219 178 255 233 246 212 other labs: pt / ptt / inr:16.0/60.9/1.4, ck / ckmb / troponin-t:1046/31/3.87, alt / ast:109/230, alk phos / t bili:97/1.2, differential-neuts:73.3 %, lymph:19.6 %, mono:5.6 %, eos:0.0 %, ca++:8.4 mg/dl, mg++:2.6 mg/dl, po4:3.3 mg/dl assessment and plan 78 yo male with a history of cad, s/p cabg [**39**] years ago, a fib, htn, dm type 2, transferred for treatment of nstemi and a fib with rvr. # nstemi: cath showed 3vd with occlusion of lad (80%) lcx and rca as well as svg. - cabg next week - continue high dose aspirin - considers starting on statin if transaminitis is better - no plavix - continue beta blockers . # systolic heart failure: ef documented to be 20-25% at osh with severe global hypokinesis. likely worsening ef secondary to large nstemi. new flush edema yesterday. - lasix boluse daily for diuresis, goal -1 lt today - monitor electrolytes [**hospital1 **] - tte showed ef 20-25% (same as osh) with severe systolic and diastolic dysfunction, moderate rv hypokinesis. - unable to give ace-i given adverse reaction . # atrial fibrillation: patient is better rate controlled currently. the patient had a run of possible a fib with aberrancy vs. v tach at osh, likely caused by nstemi. - continue metoprolol tartrate 75mg po qid for rapid a fib, consider increasing to 100 mg qid. - monitor on telemetry - on heparin gtt , transition to warfarin post cabg . # pneumonia: possibly hospital acquired pneumonia given recent hospitalization last week for 'weakness.' pt continues to spike temps overnight up to 102.1 yesterday - will continue levaquin started [**2111-3-15**], and vancomycin and ceftaz started [**2111-3-16**] to cover hap . # type 2 dm: - hold home glyburide - sliding scale insulin # transaminitis: likely secondary to low cardiac output in the setting of a large nstemi, or relative hypotension. improving. - continue to trend lfts (trending down over last few days) - hold statins for now # acute on chronic renal insuficiency: at osh, crn on presentation 1.2, with diuresis increased to 1.5. this could also be secondary to low output state. - continue to trend with diuresis # chronic thrombocytopenia: - monitor closely with heparin iv icu care nutrition: glycemic control: lines: 20 gauge - [**2111-3-19**] 05:00 pm prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: disposition:",1
394,"chief complaint: weakness hpi: 78 yo male with a history of cabg [**39**] years ago, remote mi, chronic a fib, and dm type 2 presented to osh with fatigue, weakness, cough and subjective fever. the week prior he was admitted to an outside facility for weakness which was thought to be secondary to inderal dosing. the patient saw his outpatient cardiologist following discharge, asked to wear a holter monitor which showed 3 second pauses. he was scheduled to return to dr.[**name (ni) 5748**] office this coming wednesday. . on the day of admission to [**hospital3 57**] hospital, the patient's daughter found him lying on the floor, unable to stand on his own. he denies any loc at that time. his initial vital signs were t 100.7, hr 102 (irregular) and bp 158/90. he had a cxr which showed evidence of a lul opacity. he was admitted for suspected pneumonia. he initially received levaquin and given iv fluids. as the patient became more wheezy on exam, a bnp was checked found to be 405. he was then treated with iv lasix x 1 (unclear dose). he became more dyspneic and hypoxic, then transferred to the icu. he was found to be in a rapid ventricular rate with a fib, and treated with iv lopressor. in the icu, a tte showed an ef of 20-25% with severe global hypokinesis, dilated la, mild tr, and no other valvular dysfunction. ce's were sent and the initial set showed ck 353, mb 20, trop i 15.5, then repeat at 2 am ck 395, mb 55, trop i 9.0, then prior to transfer was ck 1506, mb 299, trop i 43.3. he was given high dose aspirin, loaded with 600mg of plavix, and put on iv heparin for transfer. he was treated with iv lopressor for his rapid rate. . the patient on arrival to [**hospital1 5**], was asymptomatic. he was initially transferred to the cath lab for suspected cardiac catheterization, but given his elevated inr, the decision was made to postpone cardiac cath until the am. . on review of systems, he denies any prior history of stroke, 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. . cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . allergies: penicillins rash; last dose of antibiotics: infusions: heparin sodium - 900 units/hour other icu medications: home medications: lasix 20mg daily coumadin 2.5mg tue, [**last name (un) **], sat, sun and 5mg on mon, wed, fri allopurinol 100mg daily propranolol 10mg qid amlodipine 5mg daily glyburide 2.5mg daily aspirin 81mg daily past medical history: family history: social history: 1. cardiac risk factors: diabetes, hypertension 2. cardiac history: mi [**2069**] chronic a fib chronic right bundle branch block history of recurrent v tach -cabg: [**2073**]-percutaneous coronary interventions: none -pacing/icd: none 3. other past medical history: acute on chronic renal failure tia in [**2-8**] s/p cholecystectomy chronic thrombocytopenia multiple family members with cad occupation: drugs: none tobacco: quit 40 years ago alcohol: none other: pt married, has 3 children, lives at home with his wife review of systems: flowsheet data as of [**2111-3-16**] 09:19 pm vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.3 c (99.2 tcurrent: 37.3 c (99.2 hr: 105 (99 - 117) bpm bp: 133/68(83) {124/67(82) - 150/68(88)} mmhg rr: 30 (24 - 30) insp/min spo2: 96% heart rhythm: af (atrial fibrillation) height: 68 inch total in: 184 ml po: 180 ml tf: ivf: 4 ml blood products: total out: 0 ml 780 ml urine: 780 ml ng: stool: drains: balance: 0 ml -596 ml respiratory o2 delivery device: nasal cannula spo2: 96% physical examination vs: t= 99 bp=124/67 hr=97 rr=18 o2 sat= 97% general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no elevation of jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rhonchi heard in [**doctor last name **] segment, no crackles or wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. left upper extremity hematoma. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ labs / radiology 99 k/ul 14.9 g/dl 42.6 % 8.2 k/ul [image002.jpg] [**2107-12-5**] 2:33 a4/13/[**2110**] 08:39 pm [**2107-12-9**] 10:20 p [**2107-12-10**] 1:20 p [**2107-12-11**] 11:50 p [**2107-12-12**] 1:20 a [**2107-12-13**] 7:20 p 1//11/006 1:23 p [**2108-1-5**] 1:20 p [**2108-1-5**] 11:20 p [**2108-1-5**] 4:20 p wbc 8.2 hct 42.6 plt 99 other labs: differential-neuts:73.3 %, lymph:19.6 %, mono:5.6 %, eos:0.0 % assessment and plan 78 yo male with a history of cad, s/p cabg [**39**] years ago, a fib, htn, dm type 2, transferred for treatment of nstemi and a fib with rvr. . # nstemi: the patient has 38 year old bypass grafts, with no more recent interventions. in the setting of type 2 dm, the likelihood that these grafts have restenosed is very high. most likely the stress of having a pneumonia with a fib precipitated this event. - restart heparin drip - continue plavix 75mg daily (s/p 600mg loading at osh) - continue high dose aspirin - hold high dose statin given transaminitis - continue beta blockers - hold ace-i given his acute on chronic renal failure and adverse reaction to lisinopril (hyperkalemia) - plan for cardiac cath in am when inr less - trend ce's until peak - ekg on admission and in am . # systolic heart failure: ef documented to be 20-25% at osh with severe global hypokinesis. likely worsening ef secondary to large nstemi. - lasix for diuresis, goal uop 100cc/hr - monitor electrolytes [**hospital1 **] - consider repeat tte in am to evaluate for fixed wall motion abnormalities and ef - unable to give ace-i given adverse reaction . # atrial fibrillation: patient is in rapid ventricular rate currently. the patient had a run of possible a fib with aberrancy vs. v tach earlier today at osh, likely caused by nstemi. - will start metoprolol tartrate 25mg po bid - will use metoprolol tartrate 5mg iv prn - monitor on telemetry - hold coumadin, continue heparin drip for now . # pneumonia: possibly hospital acquired pneumonia given recent hospitalization last week for 'weakness.' - cxr on admission - will continue levaquin started [**2111-3-15**] - however, if patient has fevers or worsening leukocytosis will consider broader coverage with vancomycin and ceftaz to cover hap . # type 2 dm: - hold home glyburide - sliding scale insulin . # hypertension: - will use metoprolol instead of home propranolol in the attempt to rate control - will restart home amlodipine as needed . # transaminitis: likely secondary to low cardiac output in the setting of a large nstemi, or relative hypotension. at osh, t bili 2.6, direct 0.6, ast 288, alt 170, ap 106. - continue to trend lfts - hold statins for now . # acute on chronic renal insuficiency: at osh, crn on presentation 1.2, with diuresis increased to 1.5. this could also be secondary to low output state. - continue to trend with diuresis . # chronic thrombocytopenia: - monitor closely with heparin iv . fen: clears only overnight as may need to go to the cath lab access: piv's prophylaxis: -dvt ppx with heparin iv drip -pain managment with morphine as needed -bowel regimen code: full dispo: ccu . . icu care nutrition: comments: npo for now glycemic control: regular insulin sliding scale lines: 22 gauge - [**2111-3-16**] 07:00 pm 20 gauge - [**2111-3-16**] 07:00 pm prophylaxis: dvt: sq uf heparin stress ulcer: vap: comments: communication: comments: code status: full code disposition: icu",1
395,"chief complaint: 24 hour events: blood cultured - at [**2111-3-16**] 08:30 pm nasal swab - at [**2111-3-17**] 01:00 am [**2111-3-16**]: - gave additional dose of lopressor 5mg iv for rapid a fib - replaced k - ast elevated to 458 - cxr shows bl infiltrate worse on left upper - gave one dose of zyprexa for agitation - increased metoprolol to 50mg [**hospital1 **] - gave 5mg of vit k given for inr 3.9 - atrovent inhaler and gave extra dose of lasix 20mg iv for wheezing - attempted rate control with iv dilt 10mg x2 as rate persistently in the 110's, somewhat better control, down to 90's, so started dilt drip overnight, with not much effect . allergies: penicillins rash; last dose of antibiotics: infusions: diltiazem - 15 mg/hour heparin sodium - 600 units/hour other icu medications: metoprolol - [**2111-3-16**] 09:50 pm furosemide (lasix) - [**2111-3-17**] 12:50 am diltiazem - [**2111-3-17**] 01:15 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2111-3-17**] 06:21 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.3 c (99.2 tcurrent: 37.1 c (98.8 hr: 108 (97 - 117) bpm bp: 142/62(79) {109/58(70) - 150/101(104)} mmhg rr: 30 (23 - 31) insp/min spo2: 95% heart rhythm: af (atrial fibrillation) height: 68 inch total in: 359 ml 201 ml po: 330 ml 90 ml tf: ivf: 29 ml 111 ml blood products: total out: 885 ml 695 ml urine: 885 ml 695 ml ng: stool: drains: balance: -526 ml -494 ml respiratory support o2 delivery device: nasal cannula spo2: 95% abg: ///28/ physical examination general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no elevation of jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rhonchi heard in [**doctor last name **] segment, no crackles or wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. left upper extremity hematoma. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ labs / radiology 109 k/ul 14.9 g/dl 206 mg/dl 1.6 mg/dl 28 meq/l 3.5 meq/l 40 mg/dl 94 meq/l 134 meq/l 43.3 % 8.2 k/ul [image002.jpg] [**2111-3-16**] 08:39 pm [**2111-3-17**] 03:41 am wbc 8.2 8.2 hct 42.6 43.3 plt 99 109 cr 1.6 1.6 tropt 3.34 3.87 glucose 296 206 other labs: pt / ptt / inr:40.6/119.9/4.4, ck / ckmb / troponin-t:1046/31/3.87, alt / ast:165/458, alk phos / t bili:101/1.4, differential-neuts:73.3 %, lymph:19.6 %, mono:5.6 %, eos:0.0 %, ca++:9.1 mg/dl, mg++:2.2 mg/dl, po4:1.8 mg/dl assessment and plan 78 yo male with a history of cad, s/p cabg [**39**] years ago, a fib, htn, dm type 2, transferred for treatment of nstemi and a fib with rvr. . # nstemi: the patient has 38 year old bypass grafts, with no more recent interventions. in the setting of type 2 dm, the likelihood that these grafts have restenosed is very high. most likely the stress of having a pneumonia with a fib precipitated this event. - restart heparin drip - continue plavix 75mg daily (s/p 600mg loading at osh) - continue high dose aspirin - hold high dose statin given transaminitis - continue beta blockers - hold ace-i given his acute on chronic renal failure and adverse reaction to lisinopril (hyperkalemia) - plan for cardiac cath when inr less, however trending up, gave vit k yesterday - trend ce's until peak - ekg in am . # systolic heart failure: ef documented to be 20-25% at osh with severe global hypokinesis. likely worsening ef secondary to large nstemi. - lasix boluses for diuresis, goal uop 100cc/hr - monitor electrolytes [**hospital1 **] - tte today to evaluate for fixed wall motion abnormalities and ef - unable to give ace-i given adverse reaction . # atrial fibrillation: patient is in rapid ventricular rate currently. the patient had a run of possible a fib with aberrancy vs. v tach earlier today at osh, likely caused by nstemi. - continue metoprolol tartrate 50mg po bid - continue diltiazem drip - monitor on telemetry - hold coumadin, continue heparin drip for now . # pneumonia: possibly hospital acquired pneumonia given recent hospitalization last week for 'weakness.' - cxr on admission - will continue levaquin started [**2111-3-15**] - however, if patient has fevers or worsening leukocytosis will consider broader coverage with vancomycin and ceftaz to cover hap . # type 2 dm: - hold home glyburide - sliding scale insulin . # hypertension: - will use metoprolol instead of home propranolol in the attempt to rate control - will restart home amlodipine as needed . # transaminitis: likely secondary to low cardiac output in the setting of a large nstemi, or relative hypotension. at osh, t bili 2.6, direct 0.6, ast 288, alt 170, ap 106. trending up ast now 458, inr 3.9 - continue to trend lfts - hold statins for now . # acute on chronic renal insuficiency: at osh, crn on presentation 1.2, with diuresis increased to 1.5. this could also be secondary to low output state. - continue to trend with diuresis . # chronic thrombocytopenia: - monitor closely with heparin iv . icu care nutrition: npo as may go to cath lab today glycemic control: lines: 22 gauge - [**2111-3-16**] 07:00 pm 20 gauge - [**2111-3-16**] 07:00 pm prophylaxis: dvt: heparin drip stress ulcer: vap: comments: communication: comments: code status: full code disposition: ccu",1
396,"chief complaint: 24 hour events: blood cultured - at [**2111-3-16**] 08:30 pm nasal swab - at [**2111-3-17**] 01:00 am [**2111-3-16**]: - gave additional dose of lopressor 5mg iv for rapid a fib - replaced k - ast elevated to 458 - cxr shows bl infiltrate worse on left upper - gave one dose of zyprexa for agitation - increased metoprolol to 50mg [**hospital1 **] - gave 5mg of vit k given for inr 3.9 - atrovent inhaler and gave extra dose of lasix 20mg iv for wheezing - attempted rate control with iv dilt 10mg x2 as rate persistently in the 110's, somewhat better control, down to 90's, so started dilt drip overnight, with not much effect . allergies: penicillins rash; last dose of antibiotics: infusions: diltiazem - 15 mg/hour heparin sodium - 600 units/hour other icu medications: metoprolol - [**2111-3-16**] 09:50 pm furosemide (lasix) - [**2111-3-17**] 12:50 am diltiazem - [**2111-3-17**] 01:15 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2111-3-17**] 06:21 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 37.3 c (99.2 tcurrent: 37.1 c (98.8 hr: 108 (97 - 117) bpm bp: 142/62(79) {109/58(70) - 150/101(104)} mmhg rr: 30 (23 - 31) insp/min spo2: 95% heart rhythm: af (atrial fibrillation) height: 68 inch total in: 359 ml 201 ml po: 330 ml 90 ml tf: ivf: 29 ml 111 ml blood products: total out: 885 ml 695 ml urine: 885 ml 695 ml ng: stool: drains: balance: -526 ml -494 ml respiratory support o2 delivery device: nasal cannula spo2: 95% abg: ///28/ physical examination general: wdwn in nad. oriented x3. mood, affect appropriate. heent: ncat. sclera anicteric. perrl, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: supple with no elevation of jvp. cardiac: pmi located in 5th intercostal space, midclavicular line. irregularly irregular rhythm, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. rhonchi heard in [**doctor last name **] segment, no crackles or wheezes. abdomen: soft, ntnd. no hsm or tenderness. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no c/c/e. no femoral bruits. skin: no stasis dermatitis, ulcers, scars, or xanthomas. left upper extremity hematoma. pulses: right: carotid 2+ femoral 2+ dp 1+ pt 1+ left: carotid 2+ femoral 2+ dp 1+ pt 1+ labs / radiology 109 k/ul 14.9 g/dl 206 mg/dl 1.6 mg/dl 28 meq/l 3.5 meq/l 40 mg/dl 94 meq/l 134 meq/l 43.3 % 8.2 k/ul [image002.jpg] [**2111-3-16**] 08:39 pm [**2111-3-17**] 03:41 am wbc 8.2 8.2 hct 42.6 43.3 plt 99 109 cr 1.6 1.6 tropt 3.34 3.87 glucose 296 206 other labs: pt / ptt / inr:40.6/119.9/4.4, ck / ckmb / troponin-t:1046/31/3.87, alt / ast:165/458, alk phos / t bili:101/1.4, differential-neuts:73.3 %, lymph:19.6 %, mono:5.6 %, eos:0.0 %, ca++:9.1 mg/dl, mg++:2.2 mg/dl, po4:1.8 mg/dl assessment and plan 78 yo male with a history of cad, s/p cabg [**39**] years ago, a fib, htn, dm type 2, transferred for treatment of nstemi and a fib with rvr. # nstemi: the patient has 38 year old bypass grafts, with no more recent interventions. in the setting of type 2 dm, the likelihood that these grafts have restenosed is very high. most likely the stress of having a pneumonia with a fib precipitated this event. - restart heparin drip - continue plavix 75mg daily (s/p 600mg loading at osh) - continue high dose aspirin - hold high dose statin given transaminitis - continue beta blockers - hold ace-i given his acute on chronic renal failure and adverse reaction to lisinopril (hyperkalemia) - plan for cardiac cath when inr less, however trending up, gave vit k yesterday - trend ce's until peak - ekg in am . # systolic heart failure: ef documented to be 20-25% at osh with severe global hypokinesis. likely worsening ef secondary to large nstemi. - lasix boluses for diuresis, goal uop 100cc/hr - monitor electrolytes [**hospital1 **] - tte today to evaluate for fixed wall motion abnormalities and ef - unable to give ace-i given adverse reaction . # atrial fibrillation: patient is in rapid ventricular rate currently. the patient had a run of possible a fib with aberrancy vs. v tach earlier today at osh, likely caused by nstemi. - continue metoprolol tartrate 50mg po bid - continue diltiazem drip - monitor on telemetry - hold coumadin, continue heparin drip for now . # pneumonia: possibly hospital acquired pneumonia given recent hospitalization last week for 'weakness.' - cxr on admission - will continue levaquin started [**2111-3-15**] - will add vancomycin and ceftaz to cover hap . # type 2 dm: - hold home glyburide - sliding scale insulin . # hypertension: - will use metoprolol instead of home propranolol in the attempt to rate control - will restart home amlodipine as needed . # transaminitis: likely secondary to low cardiac output in the setting of a large nstemi, or relative hypotension. at osh, t bili 2.6, direct 0.6, ast 288, alt 170, ap 106. trending up ast now 458, inr 3.9 - continue to trend lfts - hold statins for now . # acute on chronic renal insuficiency: at osh, crn on presentation 1.2, with diuresis increased to 1.5. this could also be secondary to low output state. - continue to trend with diuresis . # chronic thrombocytopenia: - monitor closely with heparin iv . icu care nutrition: npo as may go to cath lab today glycemic control: lines: 22 gauge - [**2111-3-16**] 07:00 pm 20 gauge - [**2111-3-16**] 07:00 pm prophylaxis: dvt: heparin drip stress ulcer: vap: comments: communication: comments: code status: full code disposition: ccu",1
397,title: respiratory care: alb/atr nebs administered as ordered q 6hrs with no adverse reactions. bs are coarse bilaterally.,0
398,demographics ideal body weight: 69.9 none ideal tidal volume: 279.6 / 419.4 / 559.2 ml/kg lung sounds rll lung sounds: rhonchi rul lung sounds: diminished lul lung sounds: diminished lll lung sounds: rhonchi comments: ventilation assessment level of breathing assistance: unassisted spontaneous breathing visual assessment of breathing pattern: assessment of breathing comfort: no claim of dyspnea) comments: plan next 24-48 hours: pt given nebulizers as ordered albuterol/atrovent as ordered without any adverse reactions. mdi's of flovent with instruction and airchamber. pt performed with poor effort. continue to follow,0
399,demographics day of mechanical ventilation: 3 ideal body weight: 69.9 none ideal tidal volume: 279.6 / 419.4 / 559.2 ml/kg airway airway placement data known difficult intubation: unknown tube type ett: position: 22 cm at lip route: oral type: standard size: 8mm cuff management: vol/press: cuff pressure: 25 cmh2o cuff volume: 6 ml / air lung sounds rll lung sounds: diminished rul lung sounds: clear lul lung sounds: clear lll lung sounds: diminished secretions sputum color / consistency: tan / thick sputum source/amount: suctioned / moderate ventilation assessment level of breathing assistance: intermittent invasive ventilation visual assessment of breathing pattern: normal quiet breathing assessment of breathing comfort: no claim of dyspnea) invasive ventilation assessment: trigger work assessment: triggering synchronously plan next 24-48 hours: continue with daily rsbi tests & sbt's as tolerated; comments: am abg 7.34/56/192 rsbi=46. weaned fio2 to 40% and peep to 5. mdi's atrovent administered with no adverse reactions. reason for continuing current ventilatory support: underlying illness not resolved,0
400,"chief complaint: hypotension i saw and examined the patient, and was physically present with the icu resident for key portions of the services provided. i agree with his / her note above, including assessment and plan. hpi: 23 year old woman with normal vaginal delivery in [**month (only) **]. had labial address in [**month (only) 349**]. did not complete course of antibiotics. three days ago, noted pus and painful lesion. she restarted her bactrim without improvement. came to ed for evaluation. the abscess was incised and drained after which she developed chills and rigors. bp dropped to 80's with hr 130. given 4l of fluids. lactate was 4 and then came down to 2 with fluids. admitted to micu for further management. also got lightheaded with morphine. started on vanco and ceftriaxone in ed. has 2+ gram positive cocci in pairs and gram negative rods on gram stain of drainage. in micu showing tachycardia with minimal activity. patient admitted from: [**hospital1 5**] er history obtained from [**hospital 19**] medical records allergies: no known drug allergies last dose of antibiotics: infusions: other icu medications: other medications: past medical history: family history: social history: none no meds occupation: drugs: none tobacco: none alcohol: none other: review of systems: flowsheet data as of [**2104-5-30**] 12:51 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am hr: 126 (125 - 126) bpm bp: 102/58(66) {102/58(66) - 102/58(66)} mmhg rr: 20 (20 - 21) insp/min spo2: 98% heart rhythm: st (sinus tachycardia) total in: po: tf: ivf: blood products: total out: 0 ml 0 ml urine: ng: stool: drains: balance: 0 ml 0 ml respiratory spo2: 98% abg: //// physical examination general appearance: well nourished, no(t) no acute distress, overweight / obese, no(t) thin, no(t) anxious, no(t) diaphoretic eyes / conjunctiva: perrl, no(t) pupils dilated, no(t) conjunctiva pale, no(t) sclera edema, periorbital edema head, ears, nose, throat: normocephalic, no(t) poor dentition, no(t) endotracheal tube, no(t) ng tube, no(t) og tube cardiovascular: (pmi normal, hyperdynamic), (s1: normal, no(t) absent), (s2: normal, no(t) distant, no(t) loud, no(t) widely split , no(t) fixed), no(t) s3, no(t) s4, no(t) rub, (murmur: no(t) systolic, no(t) diastolic) peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) respiratory / chest: (expansion: symmetric, no(t) paradoxical), (percussion: resonant : , no(t) hyperresonant: , no(t) dullness : ), (breath sounds: clear : , no(t) crackles : , no(t) bronchial: , no(t) wheezes : , no(t) diminished: , no(t) absent : , no(t) rhonchorous: ) abdominal: soft, non-tender, bowel sounds present, no(t) distended, no(t) tender: , no(t) obese, left labial tenderness. wick in place. extremities: right: absent edema, left: absent edema, no(t) cyanosis, no(t) clubbing musculoskeletal: no(t) muscle wasting, no(t) unable to stand skin: warm, no(t) rash: , no(t) jaundice neurologic: attentive, follows simple commands, responds to: verbal stimuli, oriented (to): person, place, time, movement: purposeful, no(t) sedated, no(t) paralyzed, tone: normal labs / radiology 295 37.1 0.8 10 23 106 4.0 140 2.0 [image002.jpg] other labs: differential-neuts:57, band:1, lymph:42 assessment and plan hypotension tachycardia labial abscess young woman with recurrent labial abscess. shortly after incision and drainage patient developed hypotension; may have had transient bacteremia. lactate up for short time. no anion gap on electrolytes. with administration of antibiotics, patient noted lightheadedness and chest discomfort. has periorbital edema and hoarse voice suggestive of angioedema, perhaps in relation to cephalosporin. will switch antibiotics to vanco and unasyn for now. low wbc suggestive of acute infection although no bands present. recheck in the am. patient still intravascularly volume depleted. would continue to pus volume resuscitation vigorously. chest exam is clear and o2 sats excellent without supplemental oxygen. icu care nutrition: comments: full diet glycemic control: lines / intubation: comments: prophylaxis: dvt: lmw heparin stress ulcer: not indicated vap: comments: not applicable communication: patient discussed on interdisciplinary rounds , icu code status: full code disposition: icu total time spent: 45 minutes patient is critically ill ------ protected section ------ update on morning rounds: adverse reaction to vanc in ed and in icu with periorbital edema, lip swelling, rigors, tremors, hoarse voice. epipen at bedside. prn benadryl. add h2 blocker. hypotension resolved after fluid resusciation. still leukopenic with l shift. all cxs pending. current abx: unasyn for gnr and anaerobes, add bactrim for mrsa. gyn following for wound drainage. stable to transfer to floor if tolerates next dose of unasyn well. ------ protected section addendum entered by:[**name (ni) 4390**] [**name8 (md) 4391**], md on:[**2104-5-30**] 10:13 ------",1
401,"chief complaint: hypotension i saw and examined the patient, and was physically present with the icu resident for key portions of the services provided. i agree with his / her note above, including assessment and plan. hpi: 23 year old woman with normal vaginal delivery in [**month (only) **]. had labial address in [**month (only) 349**]. did not complete course of antibiotics. three days ago, noted pus and painful lesion. she restarted her bactrim without improvement. came to ed for evaluation. the abscess was incised and drained after which she developed chills and rigors. bp dropped to 80's with hr 130. given 4l of fluids. lactate was 4 and then came down to 2 with fluids. admitted to micu for further management. also got lightheaded with morphine. started on vanco and ceftriaxone in ed. has 2+ gram positive cocci in pairs and gram negative rods on gram stain of drainage. in micu showing tachycardia with minimal activity. patient admitted from: [**hospital1 5**] er history obtained from [**hospital 19**] medical records allergies: no known drug allergies last dose of antibiotics: infusions: other icu medications: other medications: past medical history: family history: social history: none no meds occupation: drugs: none tobacco: none alcohol: none other: review of systems: flowsheet data as of [**2104-5-30**] 12:51 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am hr: 126 (125 - 126) bpm bp: 102/58(66) {102/58(66) - 102/58(66)} mmhg rr: 20 (20 - 21) insp/min spo2: 98% heart rhythm: st (sinus tachycardia) total in: po: tf: ivf: blood products: total out: 0 ml 0 ml urine: ng: stool: drains: balance: 0 ml 0 ml respiratory spo2: 98% abg: //// physical examination general appearance: well nourished, no(t) no acute distress, overweight / obese, no(t) thin, no(t) anxious, no(t) diaphoretic eyes / conjunctiva: perrl, no(t) pupils dilated, no(t) conjunctiva pale, no(t) sclera edema, periorbital edema head, ears, nose, throat: normocephalic, no(t) poor dentition, no(t) endotracheal tube, no(t) ng tube, no(t) og tube cardiovascular: (pmi normal, hyperdynamic), (s1: normal, no(t) absent), (s2: normal, no(t) distant, no(t) loud, no(t) widely split , no(t) fixed), no(t) s3, no(t) s4, no(t) rub, (murmur: no(t) systolic, no(t) diastolic) peripheral vascular: (right radial pulse: not assessed), (left radial pulse: not assessed), (right dp pulse: not assessed), (left dp pulse: not assessed) respiratory / chest: (expansion: symmetric, no(t) paradoxical), (percussion: resonant : , no(t) hyperresonant: , no(t) dullness : ), (breath sounds: clear : , no(t) crackles : , no(t) bronchial: , no(t) wheezes : , no(t) diminished: , no(t) absent : , no(t) rhonchorous: ) abdominal: soft, non-tender, bowel sounds present, no(t) distended, no(t) tender: , no(t) obese, left labial tenderness. wick in place. extremities: right: absent edema, left: absent edema, no(t) cyanosis, no(t) clubbing musculoskeletal: no(t) muscle wasting, no(t) unable to stand skin: warm, no(t) rash: , no(t) jaundice neurologic: attentive, follows simple commands, responds to: verbal stimuli, oriented (to): person, place, time, movement: purposeful, no(t) sedated, no(t) paralyzed, tone: normal labs / radiology 295 37.1 0.8 10 23 106 4.0 140 2.0 [image002.jpg] other labs: differential-neuts:57, band:1, lymph:42 assessment and plan hypotension tachycardia labial abscess young woman with recurrent labial abscess. shortly after incision and drainage patient developed hypotension; may have had transient bacteremia. lactate up for short time. no anion gap on electrolytes. with administration of antibiotics, patient noted lightheadedness and chest discomfort. has periorbital edema and hoarse voice suggestive of angioedema, perhaps in relation to cephalosporin. will switch antibiotics to vanco and unasyn for now. low wbc suggestive of acute infection although no bands present. recheck in the am. patient still intravascularly volume depleted. would continue to pus volume resuscitation vigorously. chest exam is clear and o2 sats excellent without supplemental oxygen. icu care nutrition: comments: full diet glycemic control: lines / intubation: comments: prophylaxis: dvt: lmw heparin stress ulcer: not indicated vap: comments: not applicable communication: patient discussed on interdisciplinary rounds , icu code status: full code disposition: icu total time spent: 45 minutes patient is critically ill ------ protected section ------ update on morning rounds: adverse reaction to vanc in ed and in icu with periorbital edema, lip swelling, rigors, tremors, hoarse voice. epipen at bedside. prn benadryl. add h2 blocker. hypotension resolved after fluid resusciation. still leukopenic with l shift. all cxs pending. current abx: unasyn for gnr and anaerobes, add bactrim for mrsa. gyn following for wound drainage. stable to transfer to floor if tolerates next dose of unasyn well. ------ protected section addendum entered by:[**name (ni) 4390**] [**name8 (md) 4391**], md on:[**2104-5-30**] 10:13 ------ micu attending addendum i saw and examined the patient, and was physically present with the icu team for the key portions of the services provided. i agree with the note above, including the assessment and plan. ------ protected section addendum entered by:[**name (ni) 103**] [**last name (namepattern1) 104**], md on:[**2104-5-30**] 15:36 ------",1
402,"demographics day of intubation: day of mechanical ventilation: 2 ideal body weight: 61.2 none ideal tidal volume: 244.8 / 367.2 / 489.6 ml/kg airway airway placement data known difficult intubation: unknown procedure location: reason: tube type ett: position: 21 cm at teeth route: oral type: standard size: 7.5mm lung sounds rll lung sounds: diminished rul lung sounds: clear lul lung sounds: clear lll lung sounds: diminished comments: secretions sputum color / consistency: tan / thick sputum source/amount: suctioned / scant comments: ventilation assessment level of breathing assistance: visual assessment of breathing pattern: normal quiet breathing plan next 24-48 hours: reduce peep as tolerated, adjust min. ventilation to control ph reason for continuing current ventilatory support: underlying illness not resolved respiratory care shift procedures bedside procedures: comments: patient remains intubated and on mechanical ventilation, breath sounds bilaterally clear and diminished, suctioned intermittently for small amounts of thick tan secretions, peep weaned from 16 to 12 by increment of 2, follow up abgs are good, frequency decreased from 27 to 24, no adverse reaction, spo2 remained upper 90s, no distress occurred, patient will , at some point today, be transferred to micu 6.",0
403,"title: chief complaint: 24 hour events: urine culture - at [**2167-6-27**] 02:00 am with complaints of eye pain and leg pain overnight, given tylenol with substandard relief. also with hypotension to sbp 60's after receiving coreg 3.125. holding lasix until sbp>90. - speech/swallow said he is coughing while eating, but also coughing at other times. ?gerd cough vs stricture? recommended soft and thin diet, and if he's still here on monday, can do a video swallow study. - complained of cough overnight, given tessalon perles as that has helped him in the past - switched to pravastatin 40mg po daily - given lasix bolus and gtt - put out 400 in first hour then nothing, so increased dose to 10mg/hr - put out 250 in first hour (patient wearing condom cath, so urinating in spurts) - 2pm lytes showed cr 1.9 (down from 2.0 in the am) - carvedilol decreased to 3.125mg po bid - sugars 77-160's, decided to d/c glargine dose b/c only requiring 4 units of insulin sliding scale a day allergies: no known drug allergies last dose of antibiotics: infusions: other icu medications: furosemide (lasix) - [**2167-6-26**] 01:00 pm pantoprazole (protonix) - [**2167-6-26**] 09:00 pm heparin sodium (prophylaxis) - [**2167-6-27**] 12:00 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2167-6-27**] 06:55 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.8 c (98.3 tcurrent: 36.4 c (97.5 hr: 58 (57 - 75) bpm bp: 93/59(67) {76/52(43) - 107/73(79)} mmhg rr: 21 (11 - 25) insp/min spo2: 98% heart rhythm: sb (sinus bradycardia) wgt (current): 80 kg (admission): 75.4 kg height: 69 inch total in: 1,198 ml 123 ml po: 1,110 ml 120 ml tf: ivf: 88 ml 3 ml blood products: total out: 1,450 ml 300 ml urine: 1,450 ml 300 ml ng: stool: drains: balance: -252 ml -177 ml respiratory support o2 delivery device: none ventilator mode: cpap fio2: 35% spo2: 98% abg: ///23/ physical examination general appearance: well nourished, anxious eyes / conjunctiva: perrl, head, ears, nose, throat: normocephalic lymphatic: cervical wnl, supraclavicular wnl cardiovascular: (s1: normal), (s2: fixed); jvp 18cm peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: present), (left dp pulse: present) all 1+ respiratory / chest: (expansion: symmetric), (breath sounds: crackles : bibasilar at bases), poor inspiratory effort abdominal: soft, non-tender, bowel sounds present extremities: right: 1+, left: 1+ edema skin: not assessed neurologic: attentive, responds to: not assessed, oriented (to): person, place, time, movement: not assessed, tone: not assessed labs / radiology 151 k/ul 11.5 g/dl 136 mg/dl 1.9 mg/dl 23 meq/l 4.1 meq/l 45 mg/dl 98 meq/l 131 meq/l 35.2 % 10.6 k/ul [image002.jpg] : other urine chemistry urean:380 creat:57 na:44 other urine counts eos: negative no eos seen [**2167-6-24**] 08:19 pm [**2167-6-25**] 04:24 am [**2167-6-25**] 04:45 pm [**2167-6-25**] 08:08 pm [**2167-6-26**] 04:36 am [**2167-6-26**] 03:49 pm wbc 13.5 11.7 10.6 hct 34.4 36.4 35.2 plt 160 144 151 cr 1.6 1.6 2.0 2.0 1.9 tropt 4.12 3.52 4.16 4.43 4.18 glucose 102 58 [**telephone/fax (3) 7806**] other labs: pt / ptt / inr:14.6/32.4/1.3, ck / ckmb / troponin-t:475/16/4.18, alt / ast:38/73, alk phos / t bili:101/1.0, albumin:3.0 g/dl, ldh:824 iu/l, ca++:8.4 mg/dl, mg++:2.3 mg/dl, po4:4.4 mg/dl fsbs: 124, 77, 96, 107, 161,167; (77-167) assessment and plan assessment and plan: the patient is a 68 yo man with h/o cad s/p cabg in [**2158**], htn, and dm2, who presented for medical management s/p nstemi. . # coronary artery disease: the patient presented with a 12 hour history of chest pain, elevated ces, st depressions in ii, iii, avf, and v2-v4. he was found to have occluded sv grafts to the oms, and one of the grafts appeared to be acutely thrombosed. the patient is not a surgical or pci candidate, and thus it was determined that he will be optimally medically managed.. at this point troponin has increased more than 20% yesterday, and therefore he has likely had another infarct. currently, has not had an episode of chest pain in the past 24 hours. will continue to monitor as he is stable and enzymes trending down, with last troponin t 4.18 which has decreased from 4.38 in the prior set. - will continue to diurese with lasix gtt gtt 5mg/hr in order to reduce preload; consider increasing rate as patient has been oliguric in past 16 hours. - - continue carvedilol 3.125 mg [**hospital1 **] and hold for map<65 - continue asa 325 mg daily and plavix 75 mg daily - changed atorvastatin 80 mg daily to pravastatin 40 mg daily -> continue to monitor for adverse reactions of leg pain, increased ck - continue to monitor on telemetry - consider surgery consult, but re-operation would be a very high risk surgery in this patient and medical management seems more appropriate at this time . # pump: the patient does not have a history of chf, but he had extremely high ra, pa, pcwp on cardiac catheterization. his jvd was elevated on physical exam and widened split s2 which may be secondary to lbbb in setting of increased pulmonary htn. patient is not as fluid overloaded as yesterday as le edema has improved as well as jvd, but continues to have crackles on physical exam and a cough, likely secondary to pulmonary edema. his ef was 15-20% on recent tte, and he likely needs continued diuresis to reduce preload. - will continue to diurese as above - consider fluid restriction - continue to monitor uop and cr . # rhythm: the patient presented in nsr; however, he has had runs of nsvt since admission to the ccu, last run [**6-25**] at 2300 less than 10 beats. this is most likely a reperfusing rhythm. patient remains asymptomatic. continues to have sinus rhythm with pvcs. - continue to monitor on tele. . # anticoagulation: patient with apical hypokinesis and at risk for blood pooling and clot formation. since patient has had akinesis recorded on echo in [**2158**], will not anticoagulate at this time as patient is at lower risk in the chronic state. - hold for now - guaiac stools next bowel movement #dm2: the patient has a history of dm2, for which he takes glargine (65u), metformin, glyburide, and 70/30 insulin at home. - hold metformin and glyburide in the setting of recent contrast administration (fsbs in the low 100s) - monitor blood sugar today and consider giving glargine this evening as patient may need basal coverage. - fsbg and hiss - encourage po intake . #. acute on cki: the patient presented with cr of 1.6, with baseline of 1.3. likely pre-renal etiology (poor forward flow with low ci); based on bun/cr ratio >20/1 and feun = 28.15%; also with a history of intrinsic chronic renal disease as patient has long standing diabetes and hypertension. - continue to monitor cr and uop with diuresis. - continue lasix gtt as patient is fluid overloaded and # social issues: social work consult pending . icu care nutrition: comments: cardiac diet glycemic control: comments: hiss, glargine per home dose lines: 20 gauge - [**2167-6-24**] 05:39 pm prophylaxis: dvt: sub q heparin stress ulcer: ppi, gi cocktail vap: head of bed > 30 degrees comments: oob as tolerated communication: icu consent signed comments: code status: full code disposition: icu",1
404,"title: chief complaint: 24 hour events: urine culture - at [**2167-6-27**] 02:00 am with complaints of eye pain and leg pain overnight, given tylenol with substandard relief. also with hypotension to sbp 60's after receiving coreg 3.125. holding lasix until sbp>90. - speech/swallow said he is coughing while eating, but also coughing at other times. ?gerd cough vs stricture? recommended soft and thin diet, and if he's still here on monday, can do a video swallow study. - switched to pravastatin 40mg po daily - given lasix bolus and gtt - put out 400 in first hour then nothing, so increased dose to 10mg/hr - put out 250 in first hour (patient wearing condom cath, so urinating in spurts) - 2pm lytes showed cr 1.9 (down from 2.0 in the am) - carvedilol decreased to 3.125mg po bid - sugars 77-160's, decided to d/c glargine dose b/c only requiring 4 units of insulin sliding scale a day - brief apnic episodes overnight; sats in the 80 s; started cpap overnight. allergies: no known drug allergies last dose of antibiotics: infusions: other icu medications: furosemide (lasix) - [**2167-6-26**] 01:00 pm pantoprazole (protonix) - [**2167-6-26**] 09:00 pm heparin sodium (prophylaxis) - [**2167-6-27**] 12:00 am other medications: changes to medical and family history: review of systems is unchanged from admission except as noted below review of systems: flowsheet data as of [**2167-6-27**] 06:55 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 36.8 c (98.3 tcurrent: 36.4 c (97.5 hr: 58 (57 - 75) bpm bp: 93/59(67) {76/52(43) - 107/73(79)} mmhg rr: 21 (11 - 25) insp/min spo2: 98% heart rhythm: sb (sinus bradycardia) wgt (current): 80 kg (admission): 75.4 kg height: 69 inch total in: 1,198 ml 123 ml po: 1,110 ml 120 ml tf: ivf: 88 ml 3 ml blood products: total out: 1,450 ml 300 ml urine: 1,450 ml 300 ml ng: stool: drains: balance: -252 ml -177 ml respiratory support o2 delivery device: none ventilator mode: cpap fio2: 35% spo2: 98% abg: ///23/ physical examination general appearance: well nourished, anxious eyes / conjunctiva: perrl, head, ears, nose, throat: normocephalic lymphatic: cervical wnl, supraclavicular wnl cardiovascular: (s1: normal), (s2: fixed); jvp 18cm peripheral vascular: (right radial pulse: present), (left radial pulse: present), (right dp pulse: present), (left dp pulse: present) all 1+ respiratory / chest: (expansion: symmetric), (breath sounds: crackles : bibasilar at bases), poor inspiratory effort abdominal: soft, non-tender, bowel sounds present extremities: right: 1+, left: 1+ edema skin: not assessed neurologic: attentive, responds to: not assessed, oriented (to): person, place, time, movement: not assessed, tone: not assessed labs / radiology 151 k/ul 11.5 g/dl 136 mg/dl 1.9 mg/dl 23 meq/l 4.1 meq/l 45 mg/dl 98 meq/l 131 meq/l 35.2 % 10.6 k/ul [image002.jpg] : other urine chemistry urean:380 creat:57 na:44 other urine counts eos: negative no eos seen [**2167-6-24**] 08:19 pm [**2167-6-25**] 04:24 am [**2167-6-25**] 04:45 pm [**2167-6-25**] 08:08 pm [**2167-6-26**] 04:36 am [**2167-6-26**] 03:49 pm wbc 13.5 11.7 10.6 hct 34.4 36.4 35.2 plt 160 144 151 cr 1.6 1.6 2.0 2.0 1.9 tropt 4.12 3.52 4.16 4.43 4.18 glucose 102 58 [**telephone/fax (3) 7806**] other labs: pt / ptt / inr:14.6/32.4/1.3, ck / ckmb / troponin-t:475/16/4.18, alt / ast:38/73, alk phos / t bili:101/1.0, albumin:3.0 g/dl, ldh:824 iu/l, ca++:8.4 mg/dl, mg++:2.3 mg/dl, po4:4.4 mg/dl fsbs: 124, 77, 96, 107, 161,167; (77-167) assessment and plan assessment and plan: the patient is a 68 yo man with h/o cad s/p cabg in [**2158**], htn, and dm2, who presented for medical management s/p nstemi. . # coronary artery disease: the patient presented with a 12 hour history of chest pain, elevated ces, st depressions in ii, iii, avf, and v2-v4. he was found to have occluded sv grafts to the oms, and one of the grafts appeared to be acutely thrombosed. the patient is not a surgical or pci candidate, and thus it was determined that he will be optimally medically managed.. at this point troponin has increased more than 20% yesterday, and therefore he has likely had another infarct. currently, has not had an episode of chest pain in the past 24 hours. will continue to monitor as he is stable and enzymes trending down, with last troponin t 4.18 which has decreased from 4.38 in the prior set. - will continue to diurese with lasix gtt gtt 5mg/hr in order to reduce preload; consider increasing rate as patient has been oliguric in past 16 hours. - - change carvedilol 3.125 mg [**hospital1 **] to metoprolol 12.5 [**hospital1 **] and hold for map<65 - start digoxin today.25 mg po x 2; then will start at .125 daily tomorrow. - start isordil 10 mg tid today. - continue asa 325 mg daily and plavix 75 mg daily - changed atorvastatin 80 mg daily to pravastatin 40 mg daily -> continue to monitor for adverse reactions of leg pain, increased ck - continue to monitor on telemetry - consider surgery consult, but re-operation would be a very high risk surgery in this patient and medical management seems more appropriate at this time . # pump: the patient does not have a history of chf, but he had extremely high ra, pa, pcwp on cardiac catheterization. his jvd was elevated on physical exam and widened split s2 which may be secondary to lbbb in setting of increased pulmonary htn. patient is not as fluid overloaded as yesterday as le edema has improved as well as jvd, but continues to have crackles on physical exam and a cough, likely secondary to pulmonary edema. his ef was 15-20% on recent tte, and he likely needs continued diuresis to reduce preload. - will continue to diurese as above - consider fluid restriction - continue to monitor uop and cr . # rhythm: the patient presented in nsr; however, he has had runs of nsvt since admission to the ccu, last run [**6-25**] at 2300 less than 10 beats. this is most likely a reperfusing rhythm. patient remains asymptomatic. continues to have sinus rhythm with pvcs. - continue to monitor on tele. . # anticoagulation: patient with apical hypokinesis and at risk for blood pooling and clot formation. since patient has had akinesis recorded on echo in [**2158**], will not anticoagulate at this time as patient is at lower risk in the chronic state. - hold for now - guaiac stools next bowel movement #dm2: the patient has a history of dm2, for which he takes glargine (65u), metformin, glyburide, and 70/30 insulin at home. - hold metformin and glyburide in the setting of recent contrast administration (fsbs in the low 100s) - monitor blood sugar today and consider giving glargine this evening as patient may need basal coverage. - fsbg and hiss - encourage po intake . #. acute on cki: the patient presented with cr of 1.6, with baseline of 1.3. likely pre-renal etiology (poor forward flow with low ci); based on bun/cr ratio >20/1 and feun = 28.15%; also with a history of intrinsic chronic renal disease as patient has long standing diabetes and hypertension. - continue to monitor cr and uop with diuresis. - continue lasix gtt as patient is fluid overloaded and # social issues: vna at a minimum, to assess home safety and adherence to treatment, if not rehab. . icu care nutrition: comments: cardiac diet glycemic control: comments: hiss, glargine per home dose lines: 20 gauge - [**2167-6-24**] 05:39 pm prophylaxis: dvt: sub q heparin stress ulcer: ppi, gi cocktail vap: head of bed > 30 degrees comments: oob as tolerated communication: icu consent signed comments: code status: full code disposition: icu",1
405,"acute pain assessment: pt. c/o neck pain radiating to left shoulder blade & chest at rest and with breathing. had received morphine (4mg total) from earlier rn with some relief. pt. stated that he has had better relief with dilaudid in the past. action: dilaudid 0.5-2mg iv q2 prn ordered. pt. rcvd. 1mg iv dose @ 2400. hot pack to back of neck for ~ 10 minutes. repositoned. response: pt. stated relief from dilaudid within 10 minutes of dose. fell asleep. repeated dilaudid after ~ 1 hrs. plan: continue to assess pain and chart pain scale and management per pain assessment scale. atrial fibrillation (afib) assessment: pt. in nsr post mini maze procedure. hr 60 s this shift. minimal chest drng and becoming pink in color. hct stable 34; 32. action: dose of multaq 400 mg po given after extubation; from pt s own supply in omnicell. lytes monitored. response: remains in nsr with out pac s or afib. plan: continue antiarrhythmics. monitor chest drng. [**last name **] problem - [**name (ni) 10**] description in comments/factor ix deficiency assessment: minimal chest tube drng. toradol, motrin & asa on hold until hematology gives recommendation action: factor ix level drawn at 0300. pt. rcvd. factor ix recombinant 5050 units ivp @ 0338 over 11 minutes. response: infused without adverse reactions. plan: monitor coags/hct and await hematology orders.",0
406,"chief complaint: doe, chest pain. hpi: patient interviewed, notes reviewed. . history of presenting illness: mr. [**known firstname 275**] [**initial (namepattern1) **] [**last name (namepattern1) 4964**] [**known lastname 8175**] is a very nice 60 year-old gentleman with dm2, htn, dyslipidemia, and strong family history of cad who initially presented to his cardiologist with complaint of chest pain associated with exertion and dyspnea on exertion. he was also having night sweats several times during the week. he had a negative stress test one year ago. given his multiple risk factors for coronary disease, his cardiologist sent him directly to cardiac catherization. . he experienced chest pain described as a knife shooting into his chest the night before cath while in bed, while walking into the hospital, and on the cath table. during his catheterization, the patient was found to have distal tapering of lmca, 70% proximal stenosis and 80% mid stenosis of lad. he never had a plavix load prior to his cath. . upon arrival to the floor, he was comfortable without pain. ct surgery initiated evaluation for possible bypass. they have plans to take him to the or on monday [**2119-9-18**] (3 days from now). during the exam on the floor after taking a deep breath and sitting forward, the patient reported a similar knife like pain in his chest that disappeared in [**2-13**] minutes. pt described totally different pain, not associated with sob, doe, palpitations and did not modify with respiratory movements. . on review of systems, he denies any bleeding or clotting problems. [**name (ni) **] has neck and back pain which is from a bulging cervical disc. this causes numbness and tingling in his right arm. he also has chronic lower back pain. he denies blood in stool, diarrhea, nausea, vomiting, cough, fevers. . cardiac review of systems is notable for chest pain and dyspnea on exertion. patient admitted from: [**hospital1 5**] [**hospital1 **] history obtained from [**hospital 19**] medical records allergies: penicillins hives; last dose of antibiotics: infusions: nitroglycerin - 0.25 mcg/kg/min heparin sodium - 1,200 units/hour other icu medications: other medications: medications at home: aspirin 81 mg pravastatin 10 mg niacin [**2110**] mg fenofibrate nanocrystallized (tricor) 145 mg lisinopril 10 mg lantus 70 units qhs humalog 45 units qam humalog sliding scale at breakfast, lunch, and dinner (current bs-100)/5 metformin 850 mg eszopiclone 3mg levothyroxine 125 mcg lorazepam 0.5 mg percocet 1-2 tabs q6 prn pain- rarely takes sertraline 100 mg multivitamin calcium vitamin c 500 mg . medications on transfer: aspirin 325 mg po daily lisinopril 10 mg po daily heparin iv per weight-based dosing guidelines nitroglycerin 0.25-0.6 mcg/kg/min iv drip titrate to pain free and tricor *nf* 145 mg oral daily niacin sr [**2110**] mg po daily pravastatin 20 mg po daily insulin sc (per insulin flowsheet) oxycodone-acetaminophen [**2-10**] tab po q4h:prn back pain aluminum-magnesium hydrox.-simethicone 15-30 ml po qid:prn indigestion / gerd lorazepam 0.5 mg po q6h:prn anxiety zolpidem tartrate 5 mg po hs:prn insomnia sertraline 100 mg po daily levothyroxine sodium 125 mcg po daily ascorbic acid 500 mg po daily multivitamins 1 tab po daily . allergies: penicillin- swelling and hives when 12 years old. however, has taken amoxicillin recently with no adverse reactions. . zocor- muscle pains. past medical history: family history: social history: past medical history: cad- lmca and lad diabetes type ii- on insulin (followed at [**last name (un) 72**]) last a1c 7.8 on [**9-15**] dyslipidemia: cholest 212 triglyc 248 hdl 46 chol/hd 4.6 ldlcalc 116 lipid panel [**2119-9-15**] hypertension hypothyroidism: last tsh 7.6 [**6-/2118**] degenerative disc disease in cervical spine s/p appendectomy s/p left elbow surgery for tendon repair s/p right hand surgery for tendonitis s/p bilateral heel spur repair low back pain depression insomnnia . 1. cardiac risk factors: +diabetes, +dyslipidemia, +hypertension 2. cardiac history: -cabg: scheduled [**9-18**] -percutaneous coronary interventions: diagnostic cath [**9-15**] lmca: distal tapering lad 70% prox, 80% mid crossing origin of d1 and d2. d1 80% in origin. lcx: om1 40-50% at origin rca: diffuse 40-50% -pacing/icd: none strong family history of heart disease in mother's family with premature coronary artery disease. mother, brother, uncle, all have heart disease in early 50s and 60s. uncle died in 50's, mother required cabg x5 age 68. occupation: drugs: tobacco: alcohol: other: -tobacco history: quit in [**2090**]. approximately 25 years of [**2-10**]-1 pack per day. -etoh: rare use, less than one drink per week. -illicit drugs: none on disability for neck injury. used to work as electrician. lives with wife in [**name (ni) **], ma. has two adult healthy daughters, grandchildren. review of systems: constitutional resp psych [x] normal [x] normal [x] normal [] fever [] hemoptysis [] suicidal [] sweats [] wheezing [] delusions [] weightloss [] cough [] depression [] fatigue [] sob [] other: [] other: [] other: eyes gastrointestinal genitourinary [x] normal [x] normal [x] normal [] discharge [] abdominal pain [] dysuria [] blurry vision [] diarrhea [] hematuria [] double vision [] constipation [] hx of utis [] loss of vision: [] hematochezia [] hx of stds [] other: [] melena [] renal stones [] nausea [] dark urine [] vomiting [] cloudy urine [] other [] other cardiovasc endocrine msk [x] normal [x] normal [x] normal [] fluttering [] libido decreased [] swollen joint [] racing [] low energy [] myalgias [] bradycardia [] thyroid disease [] arthralgia [] htn [] sweating [] other [] other: [] excessive dry skin [] changes in hair [] other: ent skin neurological [x] normal [x] normal [x] normal [] nosebleed [] petichiae [] alertness []gum bleed [] ecchymosis [] numbness [] pain in teeth [] ulcers: [] nl sensation [] nasal drainage [] rash [] weakness [] dry mouth [] other: [] forgetful [] oral ulcers [] headache [] other: [] seizures [] tingling heme/lymph [x] wnl [] history of anemia [] easy bruising/bleeding [x] all other systems negative except as noted above flowsheet data as of [**2119-9-16**] 02:12 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 35.8 c (96.5 tcurrent: 35.8 c (96.5 hr: 52 (52 - 64) bpm bp: 102/50(61) {102/50(61) - 125/70(84)} mmhg rr: 18 (12 - 18) insp/min spo2: 97% heart rhythm: sb (sinus bradycardia) total in: 28 ml po: tf: ivf: 28 ml blood products: total out: 0 ml 0 ml urine: ng: stool: drains: balance: 0 ml 28 ml respiratory o2 delivery device: nasal cannula spo2: 97% physical examination vs: t 97.6 bp 121/72 hr 45 rr 16 o2 sat 95% ra . general: nad. oriented x3. mood, affect appropriate. heent: sclera anicteric. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: no carotid bruits. cardiac: rrr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. distant heart sounds. lungs: no chest wall deformities. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. obese. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no femoral bruits. right groin dressing is clean, dry, and intact. no hematoma. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ labs / radiology [image002.jpg] see below. . ekg 08:07: nsr at 63 with premature complexes. lad. qtc 453. qrs of 120ms with incomplete lbbb. twi in iii and avf. . ekg 19:53 after 10 seconds of stabbing chest pain: sinus brady at 46 with lad and incomplete lbbb. ? <1mm horizontal st elevations in v4-v6. twi in iii and avf persist. . ekg at 21:02: sinus brady at 57 with premature complexes. lad and incomplete lbbb. now has biphasic t waves and twi in v6. qtc 489ms . . 2d-echocardiogram: none in system . ett [**2118-9-20**]: protocol modified [**doctor first name **] - treadmill / stage time speed elevation heart blood rpp (min) (mph) (%) rate pressure 0 0-3 1.0 8 90 118/66 [**numeric identifier 8176**] 1 [**4-14**] 1.7 10 110 122/68 [**numeric identifier 8177**] 2 6-8.25 2.5 12 130 124/68 [**numeric identifier 8178**] total exercise time: 8.25 % max hrt rate achieved: 81 st depression: none interpretation: this 59 yo type ii iddm man was referred for evaluation of shortness of breath. the patient performed 8.25 min of a modified [**doctor first name 3275**] protocol ~6.2 mets and stopped for progressive shortness of breath. this represents a fair to limited exercise tolerance. no chest discomfort was reported. however the patient stated that his breathing felt ""exaggerated"" for the workload. no significant ekg changes were noted. the rhythm was sinus with rare isolated apds and vpds. blood pressure response to exercise was flat with an appropriate heart rate response. impression: possible anginal type symptoms in the absence of ischemic ekg changes. fair to limited exercise tolerance. nuclear report sent separately . cardiac cath: comments: 1. coronary angiography in this right-dominant system demonstrated one-vessel disease. the lmca had distal tapering but no angiographically apparent disease. the lad had diffuse proximal disease with up to 70% proximal stenosis and 80% mid stenosis that crossed the origin of the first and second diagonal branches. the first diagonal had a hazy 80% proximal stenosis. the lcx had no angiographically apparent disease, but the first obtuse marginal had a 50% stenosis at its origin. the rca had diffuse proximal 50% stenosis and a mid 40-50% stenosis. 2. limiting resting hemodynamics revealed elevated left-side filling pressures with an lvedp of 27 mm hg. there was mild systemic arterial hypertension with an sbp of 145 mm hg and a dbp of 77 mm hg. final diagnosis: 1. one vessel coronary artery disease. . laboratory data: 136 104 28 ------------ 4.2 24 1.1 wbc 5.6 hgb 12.1 hct 35.8 plt 172 pt: 12.6 ptt: 23.0 inr: 1.1 assessment and plan mr. [**known firstname 275**] [**initial (namepattern1) **] [**last name (namepattern1) 4964**] [**known lastname 8175**] is a very nice 60 year-old gentleman with dm2, htn, dyslipidemia, and strong family history of cad who presented with chest pain and was found to have lmca disease and is awaiting cabg, who had cp episode today and is transfered to cv-icu for monitoring. . # cad: pt presented with doe, which can be angina-equivalent and with cp, which was very suspicious for cad. timi score: 3, which gives him 13% risk at 14 days of: all-cause mortality, new or recurrent mi, or severe recurrent ischemia requiring urgent revascularization. due to high suspision he was sent directly to cardiac cath, which showed lmca and lad lessions. given these findings and most importantly in a dm patient, he certainly can benefir much more from cabg compared to pci. he was awaiting cabg and had episode of cp without ecg changes while hypertensive. it resolved in minutes and with nitroglycerin gtt. - continue aspirin 325 mg daily - continue nitroglycerin gtt with target sbp <140 mmhg and pain free - pt on heparin gtt - continue pravastatin 20 mg daily, but will discuss with pharmacy interactions with tri-cor and niacin of lipitor given his severe cad - no plavix as patient is awaiting cabg - holding bb for now, but will start as needed for target hr of 50-70 bpm - pt on lisinopril 10 mg daily - plan for cabg endoscopic on monday - will obtain cxr, ua, and tte prior to procedure - monitor on tele - starting vitamin d 1200 iu per day for decreasing cardiovascular risk . # pump - no signs of acute heart failure at the time, but patient has very low activity suggesting chronic heart failure. getting echocardiogram to assess ef. - pt on pravastatin, lisinopril; not on beta-blocker . # dm type ii with large insulin dose. last a1c above goal. will give insulin according to home dose. hold metformin because of dye load. [**month (only) 8**] need to increase basal insulin dose. - iss . # htn: given bradycardia, will not add beta-blocker. will continue home lisinopril. . # dyslipidemia: continue tricor, niacin. will change to atorvastatin in setting of acs as above. normal lfts. . # hypothyroidism: continue home dose. - check tsh given diaphoresis/ heat intolerance. . # neck/back pain: percocet prn. . # depression: continue sertraline. . # insomnia: ambien prn . # anxiety: lorazepam prn . #. degenerative disc disease in cervical spine - pt on percocet for pain control. anesthesia should be aware, given possible cervica abnromalities at time of intubation. . # fen: npo tonight for possible iabpc in case cp, achf or unstability. will monitor electrolytes, cr. . # access: piv's . # prophylaxis: heparin subq; low risk for gib (no prophylaxis needed), colace/senna. . # code: full code. icu care nutrition: glycemic control: lines: 20 gauge - [**2119-9-16**] 01:00 am prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: full code disposition: ------ protected section ------ attending; s note i agree with the notes of dr.[**last name (stitle) 8186**]. reviewed dayta amnd examined pt. no further cp on i/v nitro. ekg normal plan outlined if he became unstable. spent 45 mins on case [**first name4 (namepattern1) **] [**last name (namepattern1) 4425**] ------ protected section addendum entered by:[**name (ni) **] [**name (ni) 4425**] on:[**2119-9-16**] 09:14 ------",0
407,"chief complaint: doe, chest pain. hpi: patient interviewed, notes reviewed. . history of presenting illness: mr. [**known firstname 275**] [**initial (namepattern1) **] [**last name (namepattern1) 4964**] [**known lastname 8175**] is a very nice 60 year-old gentleman with dm2, htn, dyslipidemia, and strong family history of cad who initially presented to his cardiologist with complaint of chest pain associated with exertion and dyspnea on exertion. he was also having night sweats several times during the week. he had a negative stress test one year ago. given his multiple risk factors for coronary disease, his cardiologist sent him directly to cardiac catherization. . he experienced chest pain described as a knife shooting into his chest the night before cath while in bed, while walking into the hospital, and on the cath table. during his catheterization, the patient was found to have distal tapering of lmca, 70% proximal stenosis and 80% mid stenosis of lad. he never had a plavix load prior to his cath. . upon arrival to the floor, he was comfortable without pain. ct surgery initiated evaluation for possible bypass. they have plans to take him to the or on monday [**2119-9-18**] (3 days from now). during the exam on the floor after taking a deep breath and sitting forward, the patient reported a similar knife like pain in his chest that disappeared in [**2-13**] minutes. pt described totally different pain, not associated with sob, doe, palpitations and did not modify with respiratory movements. . on review of systems, he denies any bleeding or clotting problems. [**name (ni) **] has neck and back pain which is from a bulging cervical disc. this causes numbness and tingling in his right arm. he also has chronic lower back pain. he denies blood in stool, diarrhea, nausea, vomiting, cough, fevers. . cardiac review of systems is notable for chest pain and dyspnea on exertion. patient admitted from: [**hospital1 5**] [**hospital1 **] history obtained from [**hospital 19**] medical records allergies: penicillins hives; last dose of antibiotics: infusions: nitroglycerin - 0.25 mcg/kg/min heparin sodium - 1,200 units/hour other icu medications: other medications: medications at home: aspirin 81 mg pravastatin 10 mg niacin [**2110**] mg fenofibrate nanocrystallized (tricor) 145 mg lisinopril 10 mg lantus 70 units qhs humalog 45 units qam humalog sliding scale at breakfast, lunch, and dinner (current bs-100)/5 metformin 850 mg eszopiclone 3mg levothyroxine 125 mcg lorazepam 0.5 mg percocet 1-2 tabs q6 prn pain- rarely takes sertraline 100 mg multivitamin calcium vitamin c 500 mg . medications on transfer: aspirin 325 mg po daily lisinopril 10 mg po daily heparin iv per weight-based dosing guidelines nitroglycerin 0.25-0.6 mcg/kg/min iv drip titrate to pain free and tricor *nf* 145 mg oral daily niacin sr [**2110**] mg po daily pravastatin 20 mg po daily insulin sc (per insulin flowsheet) oxycodone-acetaminophen [**2-10**] tab po q4h:prn back pain aluminum-magnesium hydrox.-simethicone 15-30 ml po qid:prn indigestion / gerd lorazepam 0.5 mg po q6h:prn anxiety zolpidem tartrate 5 mg po hs:prn insomnia sertraline 100 mg po daily levothyroxine sodium 125 mcg po daily ascorbic acid 500 mg po daily multivitamins 1 tab po daily . allergies: penicillin- swelling and hives when 12 years old. however, has taken amoxicillin recently with no adverse reactions. . zocor- muscle pains. past medical history: family history: social history: past medical history: cad- lmca and lad diabetes type ii- on insulin (followed at [**last name (un) 72**]) last a1c 7.8 on [**9-15**] dyslipidemia: cholest 212 triglyc 248 hdl 46 chol/hd 4.6 ldlcalc 116 lipid panel [**2119-9-15**] hypertension hypothyroidism: last tsh 7.6 [**6-/2118**] degenerative disc disease in cervical spine s/p appendectomy s/p left elbow surgery for tendon repair s/p right hand surgery for tendonitis s/p bilateral heel spur repair low back pain depression insomnnia . 1. cardiac risk factors: +diabetes, +dyslipidemia, +hypertension 2. cardiac history: -cabg: scheduled [**9-18**] -percutaneous coronary interventions: diagnostic cath [**9-15**] lmca: distal tapering lad 70% prox, 80% mid crossing origin of d1 and d2. d1 80% in origin. lcx: om1 40-50% at origin rca: diffuse 40-50% -pacing/icd: none strong family history of heart disease in mother's family with premature coronary artery disease. mother, brother, uncle, all have heart disease in early 50s and 60s. uncle died in 50's, mother required cabg x5 age 68. occupation: drugs: tobacco: alcohol: other: -tobacco history: quit in [**2090**]. approximately 25 years of [**2-10**]-1 pack per day. -etoh: rare use, less than one drink per week. -illicit drugs: none on disability for neck injury. used to work as electrician. lives with wife in [**name (ni) **], ma. has two adult healthy daughters, grandchildren. review of systems: constitutional resp psych [x] normal [x] normal [x] normal [] fever [] hemoptysis [] suicidal [] sweats [] wheezing [] delusions [] weightloss [] cough [] depression [] fatigue [] sob [] other: [] other: [] other: eyes gastrointestinal genitourinary [x] normal [x] normal [x] normal [] discharge [] abdominal pain [] dysuria [] blurry vision [] diarrhea [] hematuria [] double vision [] constipation [] hx of utis [] loss of vision: [] hematochezia [] hx of stds [] other: [] melena [] renal stones [] nausea [] dark urine [] vomiting [] cloudy urine [] other [] other cardiovasc endocrine msk [x] normal [x] normal [x] normal [] fluttering [] libido decreased [] swollen joint [] racing [] low energy [] myalgias [] bradycardia [] thyroid disease [] arthralgia [] htn [] sweating [] other [] other: [] excessive dry skin [] changes in hair [] other: ent skin neurological [x] normal [x] normal [x] normal [] nosebleed [] petichiae [] alertness []gum bleed [] ecchymosis [] numbness [] pain in teeth [] ulcers: [] nl sensation [] nasal drainage [] rash [] weakness [] dry mouth [] other: [] forgetful [] oral ulcers [] headache [] other: [] seizures [] tingling heme/lymph [x] wnl [] history of anemia [] easy bruising/bleeding [x] all other systems negative except as noted above flowsheet data as of [**2119-9-16**] 02:12 am vital signs hemodynamic monitoring fluid balance 24 hours since 12 am tmax: 35.8 c (96.5 tcurrent: 35.8 c (96.5 hr: 52 (52 - 64) bpm bp: 102/50(61) {102/50(61) - 125/70(84)} mmhg rr: 18 (12 - 18) insp/min spo2: 97% heart rhythm: sb (sinus bradycardia) total in: 28 ml po: tf: ivf: 28 ml blood products: total out: 0 ml 0 ml urine: ng: stool: drains: balance: 0 ml 28 ml respiratory o2 delivery device: nasal cannula spo2: 97% physical examination vs: t 97.6 bp 121/72 hr 45 rr 16 o2 sat 95% ra . general: nad. oriented x3. mood, affect appropriate. heent: sclera anicteric. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. neck: no carotid bruits. cardiac: rrr, normal s1, s2. no m/r/g. no thrills, lifts. no s3 or s4. distant heart sounds. lungs: no chest wall deformities. resp were unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abdomen: soft, ntnd. obese. abd aorta not enlarged by palpation. no abdominial bruits. extremities: no femoral bruits. right groin dressing is clean, dry, and intact. no hematoma. skin: no stasis dermatitis, ulcers, scars, or xanthomas. pulses: right: dp 2+ pt 2+ left: dp 2+ pt 2+ labs / radiology [image002.jpg] see below. . ekg 08:07: nsr at 63 with premature complexes. lad. qtc 453. qrs of 120ms with incomplete lbbb. twi in iii and avf. . ekg 19:53 after 10 seconds of stabbing chest pain: sinus brady at 46 with lad and incomplete lbbb. ? <1mm horizontal st elevations in v4-v6. twi in iii and avf persist. . ekg at 21:02: sinus brady at 57 with premature complexes. lad and incomplete lbbb. now has biphasic t waves and twi in v6. qtc 489ms . . 2d-echocardiogram: none in system . ett [**2118-9-20**]: protocol modified [**doctor first name **] - treadmill / stage time speed elevation heart blood rpp (min) (mph) (%) rate pressure 0 0-3 1.0 8 90 118/66 [**numeric identifier 8176**] 1 [**4-14**] 1.7 10 110 122/68 [**numeric identifier 8177**] 2 6-8.25 2.5 12 130 124/68 [**numeric identifier 8178**] total exercise time: 8.25 % max hrt rate achieved: 81 st depression: none interpretation: this 59 yo type ii iddm man was referred for evaluation of shortness of breath. the patient performed 8.25 min of a modified [**doctor first name 3275**] protocol ~6.2 mets and stopped for progressive shortness of breath. this represents a fair to limited exercise tolerance. no chest discomfort was reported. however the patient stated that his breathing felt ""exaggerated"" for the workload. no significant ekg changes were noted. the rhythm was sinus with rare isolated apds and vpds. blood pressure response to exercise was flat with an appropriate heart rate response. impression: possible anginal type symptoms in the absence of ischemic ekg changes. fair to limited exercise tolerance. nuclear report sent separately . cardiac cath: comments: 1. coronary angiography in this right-dominant system demonstrated one-vessel disease. the lmca had distal tapering but no angiographically apparent disease. the lad had diffuse proximal disease with up to 70% proximal stenosis and 80% mid stenosis that crossed the origin of the first and second diagonal branches. the first diagonal had a hazy 80% proximal stenosis. the lcx had no angiographically apparent disease, but the first obtuse marginal had a 50% stenosis at its origin. the rca had diffuse proximal 50% stenosis and a mid 40-50% stenosis. 2. limiting resting hemodynamics revealed elevated left-side filling pressures with an lvedp of 27 mm hg. there was mild systemic arterial hypertension with an sbp of 145 mm hg and a dbp of 77 mm hg. final diagnosis: 1. one vessel coronary artery disease. . laboratory data: 136 104 28 ------------ 4.2 24 1.1 wbc 5.6 hgb 12.1 hct 35.8 plt 172 pt: 12.6 ptt: 23.0 inr: 1.1 assessment and plan mr. [**known firstname 275**] [**initial (namepattern1) **] [**last name (namepattern1) 4964**] [**known lastname 8175**] is a very nice 60 year-old gentleman with dm2, htn, dyslipidemia, and strong family history of cad who presented with chest pain and was found to have lmca disease and is awaiting cabg, who had cp episode today and is transfered to cv-icu for monitoring. . # cad: pt presented with doe, which can be angina-equivalent and with cp, which was very suspicious for cad. timi score: 3, which gives him 13% risk at 14 days of: all-cause mortality, new or recurrent mi, or severe recurrent ischemia requiring urgent revascularization. due to high suspision he was sent directly to cardiac cath, which showed lmca and lad lessions. given these findings and most importantly in a dm patient, he certainly can benefir much more from cabg compared to pci. he was awaiting cabg and had episode of cp without ecg changes while hypertensive. it resolved in minutes and with nitroglycerin gtt. - continue aspirin 325 mg daily - continue nitroglycerin gtt with target sbp <140 mmhg and pain free - pt on heparin gtt - continue pravastatin 20 mg daily, but will discuss with pharmacy interactions with tri-cor and niacin of lipitor given his severe cad - no plavix as patient is awaiting cabg - holding bb for now, but will start as needed for target hr of 50-70 bpm - pt on lisinopril 10 mg daily - plan for cabg endoscopic on monday - will obtain cxr, ua, and tte prior to procedure - monitor on tele - starting vitamin d 1200 iu per day for decreasing cardiovascular risk . # pump - no signs of acute heart failure at the time, but patient has very low activity suggesting chronic heart failure. getting echocardiogram to assess ef. - pt on pravastatin, lisinopril; not on beta-blocker . # dm type ii with large insulin dose. last a1c above goal. will give insulin according to home dose. hold metformin because of dye load. [**month (only) 8**] need to increase basal insulin dose. - iss . # htn: given bradycardia, will not add beta-blocker. will continue home lisinopril. . # dyslipidemia: continue tricor, niacin. will change to atorvastatin in setting of acs as above. normal lfts. . # hypothyroidism: continue home dose. - check tsh given diaphoresis/ heat intolerance. . # neck/back pain: percocet prn. . # depression: continue sertraline. . # insomnia: ambien prn . # anxiety: lorazepam prn . #. degenerative disc disease in cervical spine - pt on percocet for pain control. anesthesia should be aware, given possible cervica abnromalities at time of intubation. . # fen: npo tonight for possible iabpc in case cp, achf or unstability. will monitor electrolytes, cr. . # access: piv's . # prophylaxis: heparin subq; low risk for gib (no prophylaxis needed), colace/senna. . # code: full code. icu care nutrition: glycemic control: lines: 20 gauge - [**2119-9-16**] 01:00 am prophylaxis: dvt: stress ulcer: vap: comments: communication: comments: code status: full code disposition:",0
408,"hpi: 20m student no pmh p/w 5 days of cough, ha, rhinorrhea. reports increasing occipital ha intensity and recent n/v, lethargy and lue weakness. denies changes in vision, hearing, sensation, balance, swallowing. reports comfortable breathing. unable to find a comfortable position. denies ill contacts, recent travel or recent outdoors activities. osh head ct showed r edema w/tight basal cisterns. pt had observed twitching of the left face and arm concerning for seizure activity and was keppra loaded pta. acute disseminated encephalomyelitis assessment: pt following commands on r side, squeezes hand, lifts arm, wiggles toes, bends knee slightly. communicates by showing thumbs up or thumbs down using r hand. pupils equal and reactive ranging from 3mm to 7mm. does not open eyes even off sedation. no movements on l side. complains of pain when asked gives thumbs up for yes action: mannitol given q4h, keppra as ordered, acyclovir as ordered 1^st dose ivig given given 50mcg fentanyl for pain response: neuro exam unchanged throughout shift tolerated ivig well, no signs of adverse reaction noted. pain well controlled with fentanyl prn plan: continue mannitol q4h, checking serum sodium and osmolalities q4h also. needs mri tonight continue ivig therapy continue q1h neuro exams continue to assess/treat pain respiratory failure, acute (not ards/[**doctor last name 76**]) assessment: on cpap 10peep 5pressure support lungs sound clear, dim at bases lungs sounded slightly rhonchorous x1 action: suctioned as needed turned/repositioned q2h mouth care q4h and oral suctioning as needed response: lungs clear after suctioning sats maintained 94-97% plan: continue to assess respiratory status suction as needed continue frequent turning/repositioning, mouth care, and oral suctioning",0
409,"assessment: pt following commands on r side, squeezes hand, lifts arm, wiggles toes, bends knee slightly. communicates by showing thumbs up or thumbs down using r hand. pupils equal and reactive ranging from 3mm to 7mm. does not open eyes even off sedation. no movements on l side. action: mannitol given q4h, keppra as ordered, acyclovir as ordered 1^st dose ivig given mri done response: neuro exam unchanged throughout shift tolerated ivig well, no signs of adverse reaction noted. mri results pending plan: continue mannitol q4h, checking serum sodium and osmolalities q4h also. follow up with mri results continue ivig therapy continue q1h neuro exams respiratory failure, acute (not ards/[**doctor last name 76**]) assessment: on cpap 10peep 5pressure support lungs sound clear, dim at bases lungs sounded slightly rhonchorous x1 action: suctioned as needed turned/repositioned q2h mouth care q4h and oral suctioning as needed response: lungs clear after suctioning sats maintained 94-97% plan: continue to assess respiratory status suction as needed continue frequent turning/repositioning, mouth care, and oral suctioning",0
410,"hpi: 20m student no pmh p/w 5 days of cough, ha, rhinorrhea. reports increasing occipital ha intensity and recent n/v, lethargy and lue weakness. denies changes in vision, hearing, sensation, balance, swallowing. reports comfortable breathing. unable to find a comfortable position. denies ill contacts, recent travel or recent outdoors activities. osh head ct showed r edema w/tight basal cisterns. pt had observed twitching of the left face and arm concerning for seizure activity and was keppra loaded pta. acute disseminated encephalomyelitis assessment: pt following commands on r side, squeezes hand, lifts arm, wiggles toes, bends knee slightly. communicates by showing thumbs up or thumbs down using r hand. pupils equal and reactive ranging from 3mm to 7mm. does not open eyes even off sedation. no movements on l side. action: mannitol given q4h, keppra as ordered, acyclovir as ordered 1^st dose ivig given mri done response: neuro exam unchanged throughout shift tolerated ivig well, no signs of adverse reaction noted. mri results pending plan: continue mannitol q4h, checking serum sodium and osmolalities q4h also. follow up with mri results continue ivig therapy continue q1h neuro exams respiratory failure, acute (not ards/[**doctor last name 76**]) assessment: on cpap 10peep 5pressure support lungs sound clear, dim at bases lungs sounded slightly rhonchorous x1 action: suctioned as needed turned/repositioned q2h mouth care q4h and oral suctioning as needed response: lungs clear after suctioning sats maintained 94-97% plan: continue to assess respiratory status suction as needed continue frequent turning/repositioning, mouth care, and oral suctioning",0
411,"63yr old female patient with nhl admitted from 7f to [**hospital unit name 4**] for desensitization to rituximab. [**last name **] problem - [**name (ni) 10**] description in comments assessment: patient admitted on [**12-22**] for desensitization, which she completed in the early morning hours without any complications. action: this am hct <24, she was therefore given one unit of prbcs. she will be discharged home and will keep her outpatient appointment. response: patient did successful completed her desensitization and tolerated the blood transfusion without any adverse reactions. plan: discharge with follow-up instructions. patient left at approximately 1705 in the company of her son and grandson. discharge planning instruction given verbally and written along with list of medications. patient did verbalize an understanding of instructions.",0
412,"63yr old female patient with nhl admitted from 7f to [**hospital unit name 4**] for desensitization to rituximab. [**last name **] problem - [**name (ni) 10**] description in comments assessment: patient admitted on [**12-22**] for desensitization, which she completed in the early morning hours without any complications. action: this am hct <24, she was therefore given one unit of prbcs. she will be discharged home and will keep her outpatient appointment. response: patient did successful completed her desensitization and tolerated the blood transfusion without any adverse reactions. plan: discharge with follow-up instructions.",0
413,"74 year old man, baseline independent, p/w question of seizure activity; found to have autonomic instability concerning for brainstem lesion or pontine stroke. neurologic: sudden onset dysarthria and right sided weakness followed seizure like movements vs rigors in setting of hyperthermia. head ct negative for acute process. negative csf cx. brain mri suggestive of basilar artery stenosis. mental status improved over weekend of [**11-8**], opening eyes to verbal command,some movement on left side however pt's mental status appears to be worsening, yet improved from on admit. eegs (non-continuous) have thus far been negative for seizure. retroperitoneal bleed (rp bleed), spontaneous assessment: abdomen firm, distended, hct= 22.7 with morning labs, 2^nd unit prbcs infusing action: prbcs completed, no adverse reaction noted, repeat labs drawn, gi assessment q4 response: repeat hct 26, abdomen stable plan: continue to assess hct, gi assessment q4 altered mental status (not delirium) assessment: pt intubated and sedated on versed at 1.5 ml/hr, opens eyes spontaneously/to voice, follows commands inconsistently. tracks with eyes. moves all extremities. no signs/symptoms of pain. l arm purposeful movement noted. pupils 2 mm equal and reactive. no seizures noted. action: versed gtt decreased to 0.8 mg/hr, q4 hr neuro checks done response: no change in neuro status, versed increased to 1.0 due to increased rr, hr and bp plan: continue to wean versed as tolerated, q4 neuro checks fever (hyperthermia, pyrexia, not fever of unknown origin) assessment: t max 101.9 action: 650 mg tylenol po given as ordered, no motrin per dr. [**first name (stitle) **] due to bleed response: repeat temp = 102.1, blood, urine, and sputum cultures sent plan: monitor temp, follow up on cultures, repeat tylenol as ordered atrial fibrillation (afib) assessment: pt hr 90s-low 100s, with periods into 120s, bp 150s-180s action: hydralazine 10 mg given for hypertension, lopressor po given as ordered, lopressor 5 mg iv given as ordered for tachycardia, 5 mg diltizem given for afib with no effect, dilt gtt restarted, titrated to 15 mg/kg/hr for rate control. po dilt dose increased to 60 mg po qid. response: hr <100, bp 140s/70, map remained >60 plan: wean dilt gtt as tolerated respiratory failure, acute (not ards/[**doctor last name 76**]) assessment: pt on cmv 600 tidal volumes, 50% fio2, 5 peep, rr 20s-40s, lungs rhonchi to clear, suctioned for small to moderate amounts of thick, tan sputum action: respiratory therapy changed vent settings as ordered once to simv, & then changed pressure support levels response: pt unable to tolerate, rr 40s, returned to cmv with tidal volumes slightly lower at 500 plan: ? trach, family meeting being planned to discuss.",0
414,"74 year old man, baseline independent, p/w question of seizure activity; found to have autonomic instability concerning for brainstem lesion or pontine stroke. neurologic: sudden onset dysarthria and right sided weakness followed seizure like movements vs rigors in setting of hyperthermia. head ct negative for acute process. negative csf cx. brain mri suggestive of basilar artery stenosis. mental status improved over weekend of [**11-8**], opening eyes to verbal command,some movement on left side however pt's mental status appears to be worsening, yet improved from on admit. eegs (non-continuous) have thus far been negative for seizure. retroperitoneal bleed (rp bleed), spontaneous assessment: abdomen firm, distended, hct= 22.7 with morning labs, 2^nd unit prbcs infusing action: prbcs completed, no adverse reaction noted, repeat labs drawn, gi assessment q4 response: repeat hct 26, abdomen stable plan: continue to assess hct, gi assessment q4 altered mental status (not delirium) assessment: pt intubated and sedated on versed at 1.5 mg/hr, opens eyes spontaneously/to voice, follows commands inconsistently. tracks with eyes. moves all extremities. no signs/symptoms of pain. l arm purposeful movement noted. pupils 2 mm equal and reactive. no seizures noted. action: versed gtt decreased to 0.8 mg/hr, q4 hr neuro checks done response: no change in neuro status, versed increased to 1.0 due to increased rr, hr and bp plan: continue to wean versed as tolerated, q4 neuro checks fever (hyperthermia, pyrexia, not fever of unknown origin) assessment: t max 101.9 action: 650 mg tylenol po given as ordered response: plan: atrial fibrillation (afib) assessment: pt hr 90s-low 100s, with periods into 120s, bp 150s-180s action: hydralazine 10 mg given for hypertension, lopressor po given as ordered, lopressor 5 mg iv given as ordered for tachycardia, 5 mg diltizem given for afib with no effect, dilt gtt restarted, titrated to 15 mg/kg/hr for rate control. po dilt dose increased to 60 mg po qid. response: hr <100, bp 140s/70, map remained >60 plan: wean dilt gtt as tolerated respiratory failure, acute (not ards/[**doctor last name 76**]) assessment: action: response: plan:",0
415,"74 year old man, baseline independent, p/w question of seizure activity; found to have autonomic instability concerning for brainstem lesion or pontine stroke. neurologic: sudden onset dysarthria and right sided weakness followed seizure like movements vs rigors in setting of hyperthermia. head ct negative for acute process. negative csf cx. brain mri suggestive of basilar artery stenosis. mental status improved over weekend of [**11-8**], opening eyes to verbal command,some movement on left side however pt's mental status appears to be worsening, yet improved from on admit. eegs (non-continuous) have thus far been negative for seizure. retroperitoneal bleed (rp bleed), spontaneous assessment: abdomen firm, distended, hct= 22.7 with morning labs, 2^nd unit prbcs infusing action: prbcs completed, no adverse reaction noted, repeat labs drawn, gi assessment q4 response: repeat hct 26, abdomen stable plan: continue to assess hct, gi assessment q4 altered mental status (not delirium) assessment: pt opens eyes spontaneously/to voice, follows commands inconsistently. moves all extremities. on versed gtt at 1.5 mg/hr. no signs/symptoms of pain. l arm purposeful movement noted. pupils 2 mm equal and reactive. action: response: plan: fever (hyperthermia, pyrexia, not fever of unknown origin) assessment: action: response: plan: atrial fibrillation (afib) assessment: action: response: plan: respiratory failure, acute (not ards/[**doctor last name 76**]) assessment: action: response: plan:",0
416,"74 year old man, baseline independent, p/w question of seizure activity; found to have autonomic instability concerning for brainstem lesion or pontine stroke. neurologic: sudden onset dysarthria and right sided weakness followed seizure like movements vs rigors in setting of hyperthermia. head ct negative for acute process. negative csf cx. brain mri suggestive of basilar artery stenosis. mental status improved over weekend of [**11-8**], opening eyes to verbal command,some movement on left side however pt's mental status appears to be worsening, yet improved from on admit. eegs (non-continuous) have thus far been negative for seizure. retroperitoneal bleed (rp bleed), spontaneous assessment: abdomen firm, distended, hct= 22.7 with morning labs, 2^nd unit prbcs infusing action: prbcs completed, no adverse reaction noted, repeat labs drawn, gi assessment q4 response: repeat hct 26, abdomen stable plan: continue to assess hct, gi assessment q4 altered mental status (not delirium) assessment: pt intubated and sedated on versed at 1.5 mg/hr, opens eyes spontaneously/to voice, follows commands inconsistently. tracks with eyes. moves all extremities. no signs/symptoms of pain. l arm purposeful movement noted. pupils 2 mm equal and reactive. no seizures noted. action: versed gtt decreased to 0.8 mg/hr, q4 hr neuro checks done response: no change in neuro status, versed increased to 1.0 due to increased rr, hr and bp plan: continue to wean versed as tolerated, q4 neuro checks fever (hyperthermia, pyrexia, not fever of unknown origin) assessment: t max 101.9 action: 650 mg tylenol po given as ordered response: plan: atrial fibrillation (afib) assessment: action: response: plan: respiratory failure, acute (not ards/[**doctor last name 76**]) assessment: action: response: plan:",0
417,"pt with endocarditis aortic valve veg, good valve fx by echo. pt also has course complicated by acute renal failure/septic shock and now renal feels kidney failure is complicated picture of nephritis and atn/arf from shock as well. pt was given fluid today and yesterday in attempt to wean neo. bp is improved today and urine output has also improved he is putting out 50-80 cc per hour. although creatinine has continued to rise we are checking lytes and renal fx [**hospital1 **] next check tonight at 5 pm. he received 250 cc fluid bolus today x 2 and bp responded to that goal are maps 60-65 and good urine output, keep team updated, they wil order fluid prn. nutrition wise pt is to start calorie count tomorrow, he ate 50% of breakfast and [**location (un) **] for lunch plus team added boost glucose control tid which pt loves. pt was covered at noon for glucose 150, 2 units humalog. neuro wise pt was oob to chair all morning, sleeping when not eating lunch or otherwise stimulated attempting to get pt to stay awake so that he can sleep at night. pt is more cooperative although like yesterday he removed his bp cuff every hour o more often, he also removes his pneumoboots. family does assist him as they want him to be comfortable, and i did explain to them the importance of pneumoboots to prevent blood clots and that frequent bp checks are required. they understand. pt is o x 2, he is more cooperative and although he wants to be left alone and not bothered, he does well with negotiation time left alone and time for procedures . he has no adverse reaction to fluid, he is taking po fluids and iv, able to lay flat in bed, is not cooperative with lung exam but appears clear and slightly diminished at bases , he is on room air, sats 98-100, denies sob, and occasionally laying flat or prone in bed. he has a rash all over his back similar to yesterday, he has a diaper rash on his buttocks, he has a spot on his right thumb and on his right foot but ders states that it appears to be a heat rash blocking of swaet glands and recommended a steroid cream and frequent repositioning and a fan.",0
418,"pt with endocarditis aortic valve veg, good valve fx by echo. pt also has course complicated by acute renal failure/septic shock and now renal feels kidney failure is complicated picture of nephritis and atn/arf from shock as well. pt was given fluid today and yesterday in attempt to wean neo. bp is improved today and urine output has also improved he is putting out 50-80 cc per hour. although creatinine has continued to rise we are checking lytes and renal fx [**hospital1 **] next check tonight at 5 pm. he received 250 cc fluid bolus today x 2 and bp responded to that goal are maps 60-65 and good urine output, keep team updated, they wil order fluid prn. nutrition wise pt is to start calorie count tomorrow, he ate 50% of breakfast and [**location (un) **] for lunch plus team added boost glucose control tid which pt loves. pt was covered at noon for glucose 150, 2 units humalog. neuro wise pt was oob to chair all morning, sleeping when not eating lunch or otherwise stimulated attempting to get pt to stay awake so that he can sleep at night. pt is more cooperative although like yesterday he removed his bp cuff every hour o more often, he also removes his pneumoboots. family does assist him as they want him to be comfortable, and i did explain to them the importance of pneumoboots to prevent blood clots and that frequent bp checks are required. they understand. pt is o x 2, he is more cooperative and although he wants to be left alone and not bothered, he does well with negotiation time left alone and time for procedures . he has no adverse reaction to fluid, he is taking po fluids and iv, able to lay flat in bed, is not cooperative with lung exam but appears clear and slightly diminished at bases , he is on room air, sats 98-100, denies sob, and occasionally laying flat or prone in bed. he has a rash all over his back similar to yesterday, he has a diaper rash on his buttocks, he has a spot on his right thumb and on his right foot but ders states that it appears to be a heat rash blocking of swaet glands and recommended a steroid cream and frequent repositioning and a fan.",0
419,"valve replacement, aortic bioprosthetic (avr) assessment: pod #3 from tissue avr and cabg x3. received on epi/insulin & precedex gtts. v-paced, underlying unstable junctional overnight. cpap 10/5 50%. action: epi gtt weaned off this am. underlying rhythm monitored, 1^st degree avb 60s later in am. ecg & a-wire tracing was done to confirm 1^st degree avb. a wires do not capture. patient left on an vvi of 40. precedex gtt dc d. roxicet admin for incisional pain. vent weaned to 0 peep, 5 ps. abg wnl on sbt. pt extubated to 50% face tent. insulin gtt shut off per protocol. ivp lasix boluses admin, then lasix gtt started. lytes monitored, repleted. response: co wnl by cco and fick. filling pressures wnl. hemodynamics stable with intrinsic rhythm. pt does have pauses w/ nodal escape beats that are mostly self resolved. occastionally patient will require v pacing for a few beats before returning to 1^st degree avb 70s. blood sugars throughout afternoon stable, did not require add l insulin. no c/o pain per patient. patient very anxious, hypertensive and tachypneic after extubation. see below. currently patient breathing more comfortably. moderate response from lasix boluses, minimal response form gtt despite increase in hourly dosage. pt bloused for third time in afternoon [**name8 (md) 77**] np [**doctor last name 1827**]. plan: monitor underlying rhythm. monitor lytes replete prn. maintain vvi 40. monitor respiratory status carefully. nt suction prn. wean o2 as tolerates. monitor response to lasix, goal neg fluid balance for 24 hours. physical therapy consult tomorrow if patient able to tolerate. anxiety assessment: received patient on precedex gtt this morning, lethargic- but arousable to voice. precedex gtt dc d. patient awoke calmly and was extubated. extremely anxious as well as hypertensive after extubation. action: emotional support and reassurance provided. ruled out respiratory distress & pain. attempted verbal de-escalation. haldol x1 administered d/t patient s adverse reaction to benzodiazepines. response: patient more calm after haldol administered, however was still anxious. patient still staying that it is difficult for her to breathe. strong cough but unproductive. respiratory status declined over time since extubation. nt suctioned x1 for mod-large amount of thick yellow sputum. respiratory status improved -less accessory muscle use after ntsx. plan: monitor for anxiety vs respiratory distress. avoid benzos for anxiety as patient required a trigger on floor pre-op for agitation after benzos were administered that resulted in a code purple. impaired skin integrity assessment: see metavision for impairments. action: kinair bed. position changes every 2-3 hours. wound care consult. response: skin impairements remain the same. plan: wound care per skin care recommendations- see note. repositions q2 hours as tolerates.",1
420,"valve replacement, aortic bioprosthetic (avr) assessment: pod #3 from tissue avr and cabg x3. action: response: plan: anxiety assessment: received patient on precedex gtt this morning, lethargic- but arousable to voice. precedex gtt dc d. patient awoke calmly and was extubated. extremely anxious as well as hypertensive after extubation. action: emotional support and reassurance provided. ruled out respiratory distress & pain. attempted verbal de-escalation. haldol x1 administered d/t patient s adverse reaction to benzodiazepines. response: patient more calm after haldol administered, however was still anxious. patient still staying that it is difficult for her to breathe. respiratory status declined over time since extubation. plan: impaired skin integrity assessment: action: response: plan:",1
421,"[**2133-5-1**] 12:24 pm pulmonary angio clip # [**clip number (radiology) 22949**] reason: 34 yo kenyan male with cavitary sarcoidosis and aspergillosi contrast: optiray amt: ********************************* cpt codes ******************************** * [**numeric identifier 2552**] embo non neuro [**numeric identifier 527**] 2nd order [**last name (un) 172**]/brachiocephalic * * -51 multi-procedure same day [**numeric identifier 531**] trancatheter embolization * * [**numeric identifier 3637**] f/u status infusion/embo [**numeric identifier 6114**] thoracic angiogram * * [**numeric identifier 1578**] spinal sel angiogram [**numeric identifier 2554**] ea add'l vessel after basic a- * * non-ionic 100 cc * **************************************************************************** ______________________________________________________________________________ [**hospital 3**] medical condition: 34 year old man with above reason for this examination: 34 yo kenyan male with cavitary sarcoidosis and aspergillosis. had hemoptysis in past requiring lul lobectomy, now with rul cavity and escalating hemoptysis. bronchial angiography and possible embolization if indicated. page [**numeric identifier 18746**] with ? ______________________________________________________________________________ final report indication: 34-year-old kenyan male with cavitary sarcoidosis and invasive aspergillosis, presenting with progressive hemoptysis. radiologists: drs. [**last name (stitle) 185**], [**name5 (ptitle) 7068**] and [**name5 (ptitle) 8412**]. the attending radiologist, dr. [**last name (stitle) 185**], participated in all aspects of the procedure. technique: the procedure, indications, risks, benefits and alternatives were discussed with the patient and written consent was obtained. the right groin was prepped and draped in sterile fashion and locally anesthetized with 1% lidocaine. the right common femoral artery was punctured with a 19-gauge needle, and [**initials (namepattern4) **] [**last name (namepattern4) 180**] wire was passed centrally under fluoroscopic visualization. a 4-fr pigtail catheter was then advanced into the aortic arch and a descending thoracic aortogram was performed in the pa projection. the right intercostobronchial trunk was then catheterized using an h1 catheter and a selective arteriogram performed. a .035 glidewire was then used to superselectively catheterize the right bronchial artery. the catheter was advanced and a right bronchial arteriogram was performed. a tracker wire and catheter were then used to negotiate further into the right bronchial artery. findings: a thoracic aortogram injected from the distal portion of the arch demonstrates a descending thoracic aorta of normal caliber. there is a prominent intercostobronchial trunk on the right. the other intercostal vessels appear normal. no abnormal vessels are identified on the left. injection into the right intercostobronchial trunk demonstrates a single enlarged, tortuous right bronchial artery. no spinal artery is identified. superselective injection into the right bronchial artery demonstrates an enlarged tortuous vessel, with no opacification of the intercostal arteries. again, no spinal artery is identified. embolization: with the tip of the tracker catheter placed well into the abnormal right bronchial artery, a mixture of contrast material and three ml (over) [**2133-5-1**] 12:24 pm pulmonary angio clip # [**clip number (radiology) 22949**] reason: 34 yo kenyan male with cavitary sarcoidosis and aspergillosi contrast: optiray amt: ______________________________________________________________________________ final report (cont) of [**telephone/fax (1) 22950**] micron microspheres was manually injected under constant fluoroscopic visualization. embolization material was injected until stagnation of flow within the bronchial artery was achieved. no reflux of embolization material occurred during the procedure. an arteriogram performed after the embolization demonstrates minimal opacification of the proximal portion of the right bronchial artery, with extensive reflux of contrast into the superior intercostal vessels. the patient tolerated the procedure well. contrast: 105 ml optiray 60%. nonionic contrast was used due to previous adverse reaction to conray and because of the improved safety for bronchial artery examinations. anesthesia: local and conscious sedation. complications: none. impression: technically successful embolization of abnormally enlarged right bronchial artery. no visualization of a spinal artery. no abnormal left bronchial artery visualized.",1
422,"[**2189-9-10**] 12:08 pm mri pelvis without contrast clip # [**clip number (radiology) 6601**] reason: 34 y.o. female with h/o recurrent cervical carcinoma, s/p ra ______________________________________________________________________________ [**hospital 4**] medical condition: 34 year old woman with h/o cervical carcinoma. reason for this examination: 34 y.o. female with h/o recurrent cervical carcinoma, s/p rad hyst and radiation therapy, now with increased pelvic and left lower ext pain. please evaluate for recurrence. ______________________________________________________________________________ final report indication: 34 year old woman with history of cervical carcinoma status post radical hysterectomy and radiation therapy, now with increased pelvic and left lower extremity pain. technique: t1 in and out of phase, coronal haste, t2 sagittal, stir, and high res t2 sequences were performed. findings: status post radical hysterectomy. there is susceptibility artifact on the left, lying between the bladder and the rectum -- are there surgical clips in this location? adjacent to the artifact, there is an ill-defined 16 x 29 mm area of abnormal soft tissue intensity, hypointense on t1 with intermediate intensity on t2. no discrete mass is seen. no enlarge pelvic lymph nodes are detected. the bladder wall is not thickened. a small amount of free fluid is present within the pelvis. there is is left hydroureter, with dilatation of the renal pelvis and prominence of the calyces. the hydroureter extends down to the area of the susceptibility artifact and the adjoining area of abnormal soft tissue intensity. the right renal collecting system is within normal limits. comparison was made to ct dated [**2189-8-18**]. the area of soft tissue intensity corresponds to some ill-defined stranding seen at that time. however, no hydronephrosis was seen on the [**2189-8-18**] ct scan. impression: 1. due to the patient's previous adverse reaction to gadolinium no contrast was injected. 2. there is ill-defined abnormal soft tissue signal intensity on the left, presumably in the region of the recent surgery. nearby susceptibility artifact raises the question of a surgical clip in this location, but could also be secondary to prior (transient) instrumentation -- clinical correlation requested. 3. left hydroureter and mild hydronephrosis, new since [**2189-8-18**] ct. the transition point lies near the soft tissue intensity material and (over) [**2189-9-10**] 12:08 pm mri pelvis without contrast clip # [**clip number (radiology) 6601**] reason: 34 y.o. female with h/o recurrent cervical carcinoma, s/p ra ______________________________________________________________________________ final report (cont) susceptibility artifact. however, due to the artifact, it is difficult to confirm the exact point of transtion in relation to these findings and, therefore, it could relate to either finding.",1
423,"[**2193-10-20**] 9:53 am ct head w/ & w/o contrast; ct 100cc non ionic contrast clip # [**clip number (radiology) 32292**] reason: 60 yo male with h/o gangrene and recent skin grafting who pr field of view: 25 contrast: optiray amt: 100 ______________________________________________________________________________ [**hospital 4**] medical condition: 61 year old man with iddm, htn, fournier's gangrene reason for this examination: 60 yo male with h/o gangrene and recent skin grafting who presents with delta ms, htn and c/o severe head pain. please eval for bleeding, abscess, stroke, etc. thanks. ______________________________________________________________________________ final report ct head without and with contrast. indication: fournier's gangrene, status post recent skin grafting, presents with mental status changes and severe head pain. technique: unenhanced and contrast-enhanced ct of the brain was performed. 100 cc of optiray was administered for indication of multiple allergies, without report of adverse reaction. ct head without and with contrast: the ventricles are normal in size, without shift of normally midline structures. the [**doctor last name 181**]-white matter interface is preserved, without evidence of major vascular territorial infarction. there are no intra- or extraaxial hemorrhages. there are no pathologically enhancing lesions or fluid collections. the calvarium is intact and the visualized paranasal sinuses are well aerated. there is minimal atherosclerotic calcification of the vertebral arteries bilaterally. impression: no ct evidence of pathologic intracranial process.",0
424,"[**2127-11-11**] 11:57 am ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 68910**] ct 150cc nonionic contrast; ct reconstruction reason: duodenal ca; ? blood clot; s/p whipple contrast: optiray amt: ______________________________________________________________________________ [**hospital 4**] medical condition: 47 yo m w/ h/o duodenal ca s/p whipple, takeback reason for this examination: assess blood clot. no contraindications for iv contrast ______________________________________________________________________________ final report indication: history of duodenal cancer s/p whipple procedure and take back. please assess blood clot seen on prior study. comparisons: reference is made to the patient's most recent prior ct scan, from [**2127-10-24**]. technique: axial images of the abdomen and pelvis from the lung bases through the pubic symphysis were acquired helically, with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. coronal reformatations were performed. findings: ct of the abdomen with iv contrast: bilateral pleural effusions are present with associated lung volume loss. the overall size of the pleural effusions is increased. there is an interval increase in the amount of intrahepatic biliary ductal dilatation, especially on the left. there is disruption of the anterior abdominal wall with likely granulation tissue formation from prior surgical procedures. the blood clot seen on prior studies has rather markedly enlarged. the hematoma itself is seen best on coronal reconstructions. the hematoma occupies most of the right mid-abdomen and extends superiorly to the subhepatic space. in largest dimensions, the hematoma is 14 x 14 cm. there are additional fluid pockets to the left of mid-line beneath granulation tissue which demonstrate an enhancing rind. abundant soft tissue stranding is present adjacent to these fluid collections as well as adjacent to the hematoma. the remaining viable loops of small bowel are displaced inferiorly and laterally to the left, stretching the mesentery. an area of loculated contrast is present within the hematoma posteriorly, located anterior to the right kidney. the hematoma causes mass effect on the right kidney. the kidneys enhance symmetrically. multiple surgical drains are present within the abdomen. ct of the pelvis with iv contrast: displaced small bowel loops are present within the pelvis. there is free fluid present within the pelvis with high attenuation. a foley catheter is demonstrated within the bladder. no lytic or sclerotic osseous lesions are present. impression: interval increase in the size of abdominal hematoma, which (over) [**2127-11-11**] 11:57 am ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 68910**] ct 150cc nonionic contrast; ct reconstruction reason: duodenal ca; ? blood clot; s/p whipple contrast: optiray amt: ______________________________________________________________________________ final report (cont) displaces the bowel inferiorly. the hematoma is best seen on coronal reformatations. additional fluid collections are present within the anterior abdomen, located beneath granulation tissue.",0
425,"[**2165-10-25**] 11:14 am cta chest w&w/o c &recons; cta abd w&w/o c & recons clip # [**clip number (radiology) 71704**] cta pelvis w&w/o c & recons; ct 150cc nonionic contrast reason: s/p trauma, eval for aortic injury, abn cxr contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 74 year old woman s/p bike crash over handle bars reason for this examination: eval for aortic injury no contraindications for iv contrast ______________________________________________________________________________ final report (revised) indication: trauma fall off bike. please evaluate for aortic injury. comparisons: none. technique: axial images of the chest, abdomen, and pelvis from the lung apices to the pubic symphysis were acquired helically with 150 cc of optiray contrast. there are no adverse reactions to contrast administration. findings: ct of the chest with iv contrast: the aortic root, ascending aorta, aortic arch, and descending aorta are normal in size and contour. no asymmetrical wall thickening or hematoma is present to suggest aortic injury. no dissection is present. no pleural or pericardial effusions are present. there is bilateral apical scarring, which appears chronic in nature. there is also mild bibasilar atelectasis within the dependent portions of the lungs. no focal pulmonary nodules are identified. there is no significant axillary, mediastinum or hilar lymphadenopathy. osseous structures within the chest demonstrate no evidence of fracture or hematoma. air is present in the anterior soft tissues of the neck directly anterior to the trachea, extending cranially from the level of the manubrium. the trachea appears mildly ectatic at the superior most aspects. the subcutaneous air is most likely a result from the patient's known mandibular fracture. there is no mediastinal air. no fluid collections or blood/hematoma are seen in the visualized portions of the anterior neck adjacent to the subcutaneous air. for a detailed description of the neck soft tissue, please refer to the ct of the cervical spine. ct of the abdomen with iv contrast: no focal masses are present within the liver. there is no evidence of laceration or hematoma adjacent to the liver. the spleen is intact without evidence of hematoma. the kidneys enhance symmetrically without evidence of focal mass or obstruction. there is no evidence of laceration or perinephric stranding to indicate injury. the pancreas, gallbladder, adrenal glands, stomach, and loops of small and large bowel are unremarkable. there is no ascites or fluid within the abdomen and no significant mesenteric or retroperitoneal lymphadenopathy. the osseous structures demonstrate no evidence of fracture or soft tissue injury. there is no evidence of hematoma adjacent or surrounding the abdominal aorta to suggest injury. (over) [**2165-10-25**] 11:14 am cta chest w&w/o c &recons; cta abd w&w/o c & recons clip # [**clip number (radiology) 71704**] cta pelvis w&w/o c & recons; ct 150cc nonionic contrast reason: s/p trauma, eval for aortic injury, abn cxr contrast: optiray amt: 150 ______________________________________________________________________________ final report (revised) (cont) ct of the pelvis with iv contrast: the aortic bifurcation and common iliac vessels are unremarkable, without evidence of hematoma or injury. air is present within the bladder, most likely from foley catheter insertion. the distal colon and rectum are unremarkable. the bladder is within normal limits. there is no free fluid in the pelvis and no significant pelvic or inguinal lymphadenopathy. the osseous structures of the pelvis are within normal limits, without evidence of fracture. ct reconstructions: oblique sagittal reconstructions demonstrate no evidence of hematoma adjacent to the ascending or descending aorta within the thoracic cavity. impression: 1. no evidence for traumatic aortic injury. 2. no evidence of intra-abdominal organ injury or fracture throughout the visualized portions of the axial and appendicular skeleton. 3. air in subcutaneous tissue anterior to trachea, likely from the patient's mandible fracture.",0
426,"[**2103-10-9**] 3:17 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 27150**] ct 150cc nonionic contrast reason: evaluate for inflammatory changes, evid infection, source pa field of view: 42 contrast: optiray amt: ______________________________________________________________________________ [**hospital 4**] medical condition: 46 year old man w/etoh hx, s/p recent ccy, ercp w/sphincterectomy now with ugib/lgib worsening llq pain. reason for this examination: evaluate for inflammatory changes, evid infection, source pain. please compare with prior ct. no contraindications for iv contrast ______________________________________________________________________________ final report indication: recent upper gi/lower gi bleed and worsening left lower quadrant pain. please evaluate for inflammatory changes or evidence of infection and compare with prior ct. comparisons: ct of the abdomen and pelvis from [**2103-9-30**]. technique: axial images of the abdomen and pelvis were acquired helically with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: ct of the abdomen with iv contrast: there has been interval development of small bilateral pleural effusions. mild bibasilar atelectasis is present. no focal pulmonary nodules are identified. the visualized portions of the heart, pericardium, and great vessels are unremarkable. again demonstrated is diffuse fatty infiltration of the liver. no focal liver lesions are identified. surgical clips are present within the gallbladder fossa indicating prior cholecystectomy. there is no dilatation of the intra or extrahepatic biliary ductal system. the biliary stent seen on the prior study is no longer visualized on today's exam. the spleen, adrenal glands, pancreas, kidneys, and stomach are unremarkable. there are dilated loops of small bowel within the left upper quadrant which are of unknown significance as contrast passes freely into the rectum without evidence of obstruction. there is no ascites, and no significant mesenteric or retroperitoneal lymphadenopathy. ct of the pelvis with iv contrast: the areas of bowel wall thickening previously seen in the cecum, terminal ileum, and ascending colon are no longer seen on today's study. no significant mesenteric stranding is present. the distal ureters and bladder are unremarkable. no fluid collections suggestive of an abscess are present. there is no free fluid within the pelvis. the distal colon and rectum are unremarkable. no suspicious lytic or sclerotic osseous lesions are present. impression: 1. new bilateral small pleural effusions. 2. interval resolution of previously demonstrated bowel wall thickening. (over) [**2103-10-9**] 3:17 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 27150**] ct 150cc nonionic contrast reason: evaluate for inflammatory changes, evid infection, source pa field of view: 42 contrast: optiray amt: ______________________________________________________________________________ final report (cont) 3. no intraabdominal fluid collections or abscesses are present.",0
427,"[**2119-10-5**] 7:09 am ct chest w/contrast; ct abd w&w/o c clip # [**clip number (radiology) 19670**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: re-staging of bladder cancer contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 53 year old man with bladder cancer reason for this examination: re-staging of bladder cancer ______________________________________________________________________________ final report indications: history of bladder cancer, for stating. comparisons: ct torso from [**2119-7-27**]. technique: axial images of the torso from the lung apices through the pubic symphysis were acquired helically with 150 cc of optiray contrast, used secondary to the patient's allergy history. no adverse reactions to contrast administration. ct torso with iv contrast: ct chest: the previously visualized small lung nodules are again demonstrated, and have not significantly changed in size or appearance. other small nodules are also visualized. these lesions were not seen on the prior study, possibly due to slice selection. the overall impression of these nodules is that they are stable, but given the patient's history of bladder cancer, it should be followed on future studies. there is a small nonspecific patchy area of inflammatory change in the right lung which is of unknown significance. no significant axillary, hilar, or mediastinal lymphadenopathy is present, although some small, sub 1 cm mediastinal and axillary lymph nodes are identified. no pleural or pericardial effusions are present. ct abdomen: again demonstrated is a likely simple hepatic cyst which is unchanged in appearance. no new focal lesions are identified within the liver. the spleen, pnacreas, gallbladder, adrenal glands, stomach, and small bowel are unremarkable. the soft tissue mass identified in the anterior abdominal wall is again identified and has not significantly changed in either size or appearance. an area of retroperitoneal lymphadenopathy is demonstrated posterior to the inferior vena cava below the renal veins. this conglomeration of lymph nodes extends caudally along the psoas muscle. at the superior aspect, behind the inferior vena cava, the lymph nodes measure 12 x 23 mm, and the largest extend inferiorly along the psoas muscle measures 21 x 28 mm. there is no ascites. ct pelvis: there has been interval enlargement of the pelvic side wall lymph nodes, which are now pathologically enlarged. the largest area of lymphadenopathy is on the left measuring 15 x 26 mm. the likely lymphocele/seroma is again identified and is unchanged in size or appearance. the distal colon and rectum are unremarkable. (over) [**2119-10-5**] 7:09 am ct chest w/contrast; ct abd w&w/o c clip # [**clip number (radiology) 19670**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: re-staging of bladder cancer contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) no suspicious lytic or sclerotic osseous lesions are present. impression: 1. enlarged retroperitoneal and left pelvic side wall lymph nodes worrisome for recurrence. 2. lung nodules essentially unchanged. these results were called to dr. [**last name (stitle) 19671**] at the time of dictation.",0
428,"[**2144-11-26**] 11:34 am ct chest w/contrast; ct abdomen w/contrast clip # [**clip number (radiology) 69956**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: evaluate lungs for empyema field of view: 42 contrast: optiray amt: ______________________________________________________________________________ [**hospital 4**] medical condition: 57 year old man pedestrian struck by a car. multpile fx and widened mediastinum reason for this examination: evaluate lungs for empyema no contraindications for iv contrast ______________________________________________________________________________ final report indication: pedestrian struck by car, with multiple fractures. please evaluate lungs for empyema. comparison: ct abdomen and pelvis from [**2144-11-21**]. technique: axial images of the torso from the lung apices through the pubic symphysis were acquired helically with 150 cc optiray contrast. there were no adverse reactions to contrast administration. findings: ct chest with iv contrast: a large left-sided pleural effusion is present with associated compressive atelectasis. there is near complete collapse of the left lower lobe and partial collapse of the left upper lobe. a small to moderate sized right-sided pleural effusion is also present. no focal pulmonary nodules are identified. a small pericardial effusion is also present. again demonstrated are numerous left-sided rib fractures, with one fracture extending through the chest wall and abutting the left lung. no pneumothorax is present. ct abdomen with iv contrast: soft tissue density is present within both adrenal glands, consistent with bilateral adrenal hemorrhage. no focal lesions are present within the liver. the spleen has been surgically removed. a filter is present within the ivc. bilateral renal lacerations are present, as well as numerous simple cysts bilaterally. the kidneys enhance symmetrically without evidence of obstruction. a fluid collection is present adjacent to the pancreatic tail. two other small fluid collections are present, one in the right lower quadrant, the other in the right mid mesentery. the gallbladder also appears mildly distended with wall thickening, as well as a small pericholecystic fluid collection adjacent to the liver. extensive soft tissue edema is present in the body wall. ct pelvis with iv contrast: free fluid is present within the pelvis. there is stranding adjacent to the cecum consistent with patient's prior appendicitis. the rectum is unremarkable. no fractures are present throughout the visualized portions of the pelvis or lumbar spine. no lytic or sclerotic osseous lesions are present. (over) [**2144-11-26**] 11:34 am ct chest w/contrast; ct abdomen w/contrast clip # [**clip number (radiology) 69956**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: evaluate lungs for empyema field of view: 42 contrast: optiray amt: ______________________________________________________________________________ final report (cont) impression: 1. large left-sided pleural effusion with multiple rib fractures and compressive atelectasis. 2. bilateral adrenal hemorrhages. 3. slightly distended gallbladder with wall thickening and small pericholecystic fluid collection. future follow up with ultrasound to evaluate for acute cholecystitis may be performed if clinically indicated. 4. multiple small fluid collections within the right lower quadrant and right mid mesentery, as well as free fluid within the pelvis.",0
429,"[**2183-11-7**] 7:38 am ct chest w/contrast; ct abd w&w/o c clip # [**clip number (radiology) 34529**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: 72 yo gentleman with hx of transitional cell carcinoma of th field of view: 44 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 72 year old man with hx of transitional cell carcinoma reason for this examination: 72 yo gentleman with hx of transitional cell carcinoma of the kidney metastatic to the paraaortic nodes s/p 5 cycles of chemotherapy and with a hx of continued slow gi bleed. please rule out disease recurrence and please compare to previous ct scans. ______________________________________________________________________________ final report indication: history of transitional cell cancer of the kidney metastatic to the para aortic nodes with five prior cycles of chemotherapy and continued slow gi bleed. comparisons: ct torso [**2183-5-26**]. technique: axial images of the torso from the lung apices through the pubic symphysis were acquired helically with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. optiray used secondary to prior nephrectomy. ct chest with contrast: no significant axillary, mediastinal, or hilar lymphadenopathy is present. the heart is unremarkable with the exception of coronary arterial calcification. the aorta demonstrates areas of calcification. no focal lung nodules or parenchymal opacities are present. no pleural or pericardial effusions are present. ct abdomen with contrast: no focal masses are present within the liver. the spleen demonstrates a splenule. the adrenal glands, pancreas, gallbladder, stomach and small bowel are unremarkable. there is no ascites. there is no significant mesenteric lymphadenopathy. surgical clips are present within the left retroperitoneum consistent with patient's prior nephrectomy. the right kidney enhances homogeneously without evidence of obstruction. no filling defects are present within the calyces or pelvis. there is a small amount of soft tissue adjacent to the surgical clips in the right renal fossa. no pathologically enlarged lymph nodes are present in this area on today's exam. vascular calcifications are present within the aorta. there is no ascites. ct pelvis with contrast: the distal ureter and bladder are unremarkable. scattered small diverticulae are present within the ascending colon without evidence of diverticulitis. the sigmoid colon and rectum are unremarkable. there is no free fluid in the pelvis and no significant pelvic or inguinal lymphadenopathy. the prostate gland demonstrates several calcifications but is otherwise normal in size. within each iliac [**doctor first name 1654**] is a dense area of attenuation consistent with bone islands. no suspicious lytic or sclerotic osseous lesions are present. (over) [**2183-11-7**] 7:38 am ct chest w/contrast; ct abd w&w/o c clip # [**clip number (radiology) 34529**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: 72 yo gentleman with hx of transitional cell carcinoma of th field of view: 44 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) impression: no evidence of tumor recurrence or distant metastasis.",0
430,"[**2176-11-29**] 10:58 am ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 110624**] ct 150cc nonionic contrast reason: eval for free air, abscess, any signs of perf two days post field of view: 36 contrast: optiray amt: 150cc ______________________________________________________________________________ [**hospital 2**] medical condition: 31 year old woman with peritonitis reason for this examination: eval for free air, abscess, any signs of perf two days post d/c no contraindications for iv contrast ______________________________________________________________________________ final report (revised) indication: abortion two days ago, clinical signs of peritonitis. please evaluate for abscess or perforation. comparisons: none. technique: axial images of the abdomen and pelvis from the lung bases to the pubic symphysis were acquired helically with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. coronal reformations were made. findings ct of the abdomen with iv contrast: bibasilar atelectasis is present. no focal pulmonary nodules are identified. the visualized portions of the heart, great vessels, and pericardium are unremarkable. there is a focal area of decreased attenuation within the liver adjacent to the falciform ligament which is consistent with focal fatty infiltration. the spleen, pancreas, adrenal glands, and gallbladder are unremarkable. a simple cyst is present within the midportion of the right kidney. the kidneys otherwise enhance symmetrically without evidence of obstruction. the stomach and small bowel are not opacified as the patient refused oral contrast. there is no ascites. ct of the pelvis with iv contrast: the cecum is markedly distended with air, measuring 8.7 cm in greatest dimension. there is no evidence of acute appendicitis. no focal fluid collections are present within the pelvis to suggest abscess. the uterus is large, and slightly larger than expected for a 10 to 11 week uterus. air is also present within the endometrial cavity which is consistent with the patient's history of prior abortion. these findings are concerning for endomyometritis with possible localized ileus in the cecum as a result. no significant amount of free fluid is present within the pelvis. ct reconstructions: coronal reformations demonstrate a large uterus and a markedly dilated cecum. impression: enlarged uterus suspicious for endomyometritis. marked dilatation of the cecum, secondary to possible localized ileus from inflammed uterus. alternatively cecal bascule to be considered. these findings were discussed with the surgical and gynecological house staff at the time of interpretation. (over) [**2176-11-29**] 10:58 am ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 110624**] ct 150cc nonionic contrast reason: eval for free air, abscess, any signs of perf two days post field of view: 36 contrast: optiray amt: 150cc ______________________________________________________________________________ final report (revised) (cont)",0
431,"[**2166-1-30**] 2:53 pm ct chest w/contrast; ct 100cc non ionic contrast clip # [**clip number (radiology) 60359**] reason: met renal cell ca, bilat upper ext edema, ? svc syndrome contrast: optiray amt: 100 ______________________________________________________________________________ [**hospital 2**] medical condition: 75 year old man with metastatic renal cell ca with bilateral pleural effusions with unexplained bilateral upper extremity edema and hypotension. please r/o svc syndrome. please do at the same time as head ct.needs to happen at 3pm today because is getting premedicated with steroids for iv contrast allergy. is on hemodialysis so no contraindication for kidneys. reason for this examination: r/o svc syndrome and please comment on placement of triple lumen catheter. thanks. no contraindications for iv contrast ______________________________________________________________________________ final report indication: metastatic renal cell carcinoma. unexplained bilateral upper extremity edema. evaluate for possible superior vena cava obstruction. comparison is made to previous chest ct of [**2162-5-12**]. comparison is also made to more recent ct torso study dated [**2166-1-6**]. helical ct of the thorax was performed following intravenous administration of 100 cc of optiray. nonionic contrast was administered due to history of previous contrast reaction. the patient was premedicated prior to the exam and no reported adverse reactions were noted. there is extensive mediastinal lymphadenopathy, the markedly enlarged right paratracheal lymph nodes result in high grade narrowing of the superior vena cava, particularly at the confluence of the brachiocephalic veins. there are numerous collateral vessels in the right hemithorax anteriorly and posteriorly extending into the soft tissues of the lower neck. note is also made of contrast within dilated internal mammary vessels on the right and within paraspinal collateral vessels on the right side. there is also reflux of contrast into the azygos vein which appears distended. the observed findings are consistent with high grade svc narrowing. note is also made of absence of contrast opacification within the right internal jugular vein and the right brachiocephalic vein likely due to thrombosis. note is also made of a malpositioned catheter extending from the right side of the neck into the right subclavian vein. although the superior vena cava is markedly narrow proximally, it is patent distally at the level of the azygos arch and below this level. just above the confluence with the azygos vein, note is made of a filling defect within the superior vena cava which may represent thrombus or tumor. with regard to the mediastinum, there is extensive lymphadenopathy, most pronounced within the right paratracheal and precarinal regions, but also involving the left prevascular, left paratracheal and aorticopulmonary window stations. subcarinal lymph nodes are also observed. the confluent nodes in the left paratracheal and subcarinal regions result in obstruction of the left main stem bronchus. the left lung appears completely collapsed, likely on the bases of extrinsic compression of the airway. (over) [**2166-1-30**] 2:53 pm ct chest w/contrast; ct 100cc non ionic contrast clip # [**clip number (radiology) 60359**] reason: met renal cell ca, bilat upper ext edema, ? svc syndrome contrast: optiray amt: 100 ______________________________________________________________________________ final report (cont) there are bilateral pleural effusions, moderate to large on the right and large in size on the left. a posterior chest wall mass with partial rib destruction is seen posteriorly in the lower right hemithorax. in the imaged portion of the upper abdomen, there are extensive hepatic metastases. note is made of a large mass in the right renal fossa. the right adrenal gland is normal in appearance. the left adrenal gland is not well demonstrated. the spleen appears heterogeneous, possibly due to phase of contrast administration. assessment of the lungs demonstrates extensive pulmonary metastases within the right lung. overall, these have progressed compared to the previous examination. the collapse of the left lung appears new in the interval. note is also made of distention of the thoracic esophagus without a definable obstructing mass. a hiatal hernia is also noted. skeletal structures of the thorax demonstrates lytic lesion within the upper lumbar spine which is without change compared to the previous examination. as mentioned, there is also a soft tissue mass with rib expansion and destruction in the right posterolateral chest wall. the mass appears enlarged compared to the previous study. impression: high grade narrowing of upper superior vena cava with extensive collateral vessels consistent with svc obstruction. there is also apparent obstruction of right-sided venous structures proximal to this level as detailed above. the etiology is likely due to extensive compression by enlarged mediastinal lymph nodes. the svc appears patent more distally at the level of the azygos arch and below. extensive mediastinal lymph node enlargement. in addition to svc compression, there is obstruction of the left main stem bronchus just beyond its origin. there is associated complete collapse of the left lung. worsening pulmonary metastases. skeletal metastases as detailed above the progression in size of chest wall mass in the lower right hemithorax posteriorly with associated rib destruction. extensive hepatic metastases and large soft tissue mass within the right renal (over) [**2166-1-30**] 2:53 pm ct chest w/contrast; ct 100cc non ionic contrast clip # [**clip number (radiology) 60359**] reason: met renal cell ca, bilat upper ext edema, ? svc syndrome contrast: optiray amt: 100 ______________________________________________________________________________ final report (cont) fossa, both incompletely imaged on this study. malpositioned right internal jugular line, extending into the left subclavian vein.",0
432,"[**2156-11-26**] 9:04 am ct chest w/contrast; ct abd w&w/o c clip # [**clip number (radiology) 23682**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: restaging ct scan. compare to prior studies. measure any l field of view: 42 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 33 year old man with metastatic testicular cancer. reason for this examination: restaging ct scan. compare to prior studies. measure any lesions bidimensionally and record in oncology table. ______________________________________________________________________________ final report indication: metastatic testicular cancer, for restaging. comparison is made to the prior studies from [**6-11**] and [**2156-9-10**]. technique: axial images of the torso from the lung apices to the pubic symphysis were acquired helically, with 150 cc of optiray contrast, secondary to patient's history of allergies. there are no adverse reactions to contrast administration. findings: ct of the chest with iv contrast: again demonstrated is a fullness in the left apical/axillary region, which likely represents post surgical change, and is stable in appearance since [**2156-6-11**]. the patient is status post left pneumonectomy. post surgical changes in the left hemithorax are stable in appearance. the right lung is hyperexpanded. no new areas of axillary, mediastinal or hilar lymphadenopathy are seen. the heart and great vessels are shifted to the right, but are otherwise unremarkable. no pleural effusions are present. the previously seen right sided, sub-cm basilar pulmonary nodule is again demonstrated, and is not significantly changed. ct of the abdomen with iv contrast: no focal liver lesions are identified. the spleen, pancreas, gallbladder, adrenal glands, stomach and intraabdominal loops of small and large bowel are within normal limits. the kidneys enhance symmetrically without evidence of focal mass or obstruction. there is no ascites. there is no significant mesenteric or retroperitoneal lymphadenopathy. ct of the pelvis with iv contrast: the distal ureters and bladder are within normal limits. the sigmoid colon and rectum are unremarkable. there is no free fluid in the pelvis and no significant pelvic or inguinal lymphadenopathy. both testicles are visualized. impression: no evidence of recurrent disease. overall appearance unchanged since [**2156-6-11**]. (over) [**2156-11-26**] 9:04 am ct chest w/contrast; ct abd w&w/o c clip # [**clip number (radiology) 23682**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: restaging ct scan. compare to prior studies. measure any l field of view: 42 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont)",0
433,"[**2193-1-9**] 11:03 am ct abd w&w/o c; ct pelvis w&w/o c clip # [**clip number (radiology) 58956**] ct 150cc nonionic contrast; ct reconstruction reason: 81m with hematuria, r/o tumor of [**name (ni) 58957**], unclear etiology field of view: 40 contrast: optiray amt: 150cc ______________________________________________________________________________ [**hospital 2**] medical condition: 81 year old man with hematuria of unclear etiology. reason for this examination: 81m with hematuria, acute myocardial infarction, pre-op now for coronary bypass surgery. needs ct-abd+pelvis with delayed images and 3mm cuts. we are looking for a tumor (esp. bladder/ureter tumor) as cause of the hematuria. no contraindications for iv contrast ______________________________________________________________________________ final report indication: hematuria, evaluate for bladder/ureter tumor. reference is made to the patient's renal ultrasound from [**2193-1-8**]. technique: axial images of the abdomen and pelvis from the lung bases through the pubic symphysis were aquired helically before and after the administration of 150 cc of optiray contrast, used secondary to the patient's history of debility. there were no adverse reactions to contrast administration. findings: ct abdomen with iv contrast: multiple calcified pleural plaques are present. study is limited by patient motion. no liver lesions are identified. the spleen, adrenal glands, pancreas, gallbladder, stomach, and intraabdominal loops of bowel are within normal limits. several small, nonpathologically enlarged paraaortic lymph nodes are seen. there is no ascites. both kidneys enhance symmetrically without evidence of obstruction. multiple simple renal cysts are present bilaterally. no filling defects are present within either renal collecting system or ureter. ct pelvis with iv contrast: the distal ureters and bladder are unremarkable. the prostate is large, and slightly heterogeneous in enhancement. allowing for limitations due to patient movement, the distal large bowel and rectum are unremarkable. there is no free fluid in the pelvis and no significant pelvic or inguinal lymphadenopathy. no suspicious lytic or sclerotic osseous lesions are identified. impression: 1) no evdience of bladder or ureteral cancer. 2) multiple simple renal cysts bilaterally. these results were discussed with the clinical house staff at the time of interpretation. (over) [**2193-1-9**] 11:03 am ct abd w&w/o c; ct pelvis w&w/o c clip # [**clip number (radiology) 58956**] ct 150cc nonionic contrast; ct reconstruction reason: 81m with hematuria, r/o tumor of [**name (ni) 58957**], unclear etiology field of view: 40 contrast: optiray amt: 150cc ______________________________________________________________________________ final report (cont)",0
434,"[**2121-1-15**] 1:32 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 62668**] ct 150cc nonionic contrast reason: 53 yo female s/p multiple orthopedic procedures with recentl field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 53 year old woman with recently diagnosed lumbar spine e.coli s/p multiple spinal surgery and resection of left 11th rib. reason for this examination: 53 yo female s/p multiple orthopedic procedures with recently diagnosed e. coli infected hardware in lumbar spine. pt. with pain in left upper quadrant/left cva in region of previous rib resection. query hematoma/infection in this region. ______________________________________________________________________________ final report indications: multiple prior orthopedic procedures, e. coli infected hardware in lumbar spine, pain in left upper quadrant. comparison is made to the prior abdominal ct from [**2120-11-18**]. technique: axial images of the abdomen and pelvis were acquired helically with 150 cc of optiray contrast, used secondary to the patient's allergy history. there were no adverse reactions to contrast administration. findings: ct of the abdomen with iv contrast: two tiny, sub-5-mm pulmonary nodules are identified in the right lung base. no pleural or pericardial effusions are seen. the liver demonstrates a diffuse decrease in attenuation consistent with fatty infiltration. no focal liver lesions are identified. the spleen, pancreas, gallbladder, adrenal glands, stomach, and intraabdominal loops of small and large bowel are within normal limits. there is no stranding of the fat in the left upper quadrant. there is no ascites. there is no significant mesenteric or retroperitoneal lymphadenopathy. the kidneys enhance symmetrically without evidence of focal mass or obstruction. ct of the pelvis with iv contrast: the distal ureters and bladder are within normal limits. again demonstrated is a degenerating uterine fibroid. the sigmoid colon and rectum are normal. there is no free fluid in the pelvis and no significant inguinal or pelvic lymphadenopathy. extensive postsurgical changes are present within the distal thoracic and lumbar spine, including posterior [**location (un) 7282**]-type rods, a vertebral body cage prosthesis, and intravertebral body screws with left lateral fixation. there is no evidence of hardware loosening, or lucent areas adjacent to the hardware itself. the patient has has posterior laminectomies at multiple levels. changes from likely bone harvest for graft material are present within both iliac bones. no suspicious lytic or sclerotic osseous lesions are identified. impression: postsurgical changes from extensive lumbar surgery. unchanged degenerating fibroid. no acute changes. (over) [**2121-1-15**] 1:32 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 62668**] ct 150cc nonionic contrast reason: 53 yo female s/p multiple orthopedic procedures with recentl field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont)",0
435,"[**2139-11-27**] 8:21 am cta chest w&w/o c &recons; ct 100cc non ionic contrast clip # [**clip number (radiology) 71572**] reason: chest pain sob contrast: optiray amt: ______________________________________________________________________________ [**hospital 4**] medical condition: 52 year old man with pleuritic cp, tachycardia, sob, no clear infiltrate on cxr. reason for this examination: eval for pe no contraindications for iv contrast ______________________________________________________________________________ wet read: eez [**first name9 (namepattern2) 315**] [**2139-11-27**] 9:29 am no pe. left lingular pneumonia. ______________________________________________________________________________ final report indication: pleuritic chest pain, tachycardiac, shortness of breath, question marked pe. no prior ct's are available for comparison. technique: axial images of the chest from the lung bases through the lung apices were aquired helically, with 150 cc of optiray contrast, fast bolus, per pe protocol. there were no adverse reactions to contrast administration. ct chest with iv contrast: there is mild prominence of the thyroid gland. this study is slightly limited technically. the pulmonary vasculature is visualized, and contains no intraluminal filling defects to suggest pulmonary embolus. there is an area of consolidation in the lingular portion of the left upper lobe, which likely represents pneumonia. dependent changes are present within both lung bases. no pleural or pericardial effusions are present. the heart and great vessels are unremarkable. there are several scattered, nonpathologically enlarged mediastinal lymph nodes within the ap window. no significant axillary lymphadenopathy is noted. impression: 1) no evidence of pulmonary embolus. 2) left lingular pneumonia.",0
436,"[**2148-1-5**] 1:59 pm cta abd w&w/o c & recons; ct abdomen w/contrast clip # [**clip number (radiology) 13500**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: painless jaundice field of view: 40 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 2**] medical condition: 58 year old man with reason for this examination: painless jaundice ______________________________________________________________________________ final report indication: painless jaundice. no prior studies are available for comparison. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases through the pubic symphysis, with 150 cc of optiray contrast, and multiple phases, per pancreas cta protocol. there were no adverse reactions to contrast administration. coronal reformations were made. findings: ct of the abdomen with iv contrast: minimal dependent changes are present within both lung bases. no focal pulmonary nodules are identified. no pleural or pericardial effusions are present. no focal liver masses are identified. there is dilation of both the right and left intrahepatic biliary ducts. near the formation of the common hepatic duct, there is a 16 x 20 mm soft tissue attenuating mass, which demonstrates questionable late enhancement. the common bile duct is not dilated distal to this mass. the differential diagnosis for this mass includes cholangiocarcinoma (klatskin tumor). follow-up with ercp or mrcp should be performed. near the neck of the pancreas is an area of soft tissue density, which may represent a pancreatic lobulation or lymph node. the pancreas is otherwise normal. the right hepatic artery courses extremely near to the lesion. the left hepatic artery, gda, and superior mesenteric artery, as well as the portal vein, are within normal limits. numerous paraaortic retroperitoneal lymph nodes are seen which do not meet size criteria in short axis for pathological enlargement. the duodenum is unremarkable. the adrenal glands, spleen, stomach and remaining intraabdominal loops of small and large bowel are unremarkable. there is no ascites. ct of the pelvis with iv contrast: the distal ureters, bladder, prostate, sigmoid colon, and rectum are within normal limits. there is no free fluid in the pelvis and no pathological inguinal or pelvic lymphadenopathy. no suspicious lytic or sclerotic osseous lesions are identified. degenerative changes are present within the sacroiliac joints, including vacuum phenomenon within the adjacent right ilium. impression: mass near bifurcation of right and left hepatic ducts. the differential (over) [**2148-1-5**] 1:59 pm cta abd w&w/o c & recons; ct abdomen w/contrast clip # [**clip number (radiology) 13500**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: painless jaundice field of view: 40 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) includes cholangiocarcinoma. follow-up with ercp or mrcp is recommended. these results were discussed with dr. [**first name4 (namepattern1) 4881**] [**last name (namepattern1) 13501**] at the time of interpretation.",0
437,"[**2142-1-3**] 9:10 am cta chest w&w/o c &recons; ct 100cc non ionic contrast clip # [**clip number (radiology) 14719**] reason: eval for recurrent pes contrast: optiray amt: 100 ______________________________________________________________________________ [**hospital 3**] medical condition: 23 year old man with antiphospholipid syndrome, recent dvt/saddle embolus, currently on lovenox/coumadin, p/w massive hemoptysis reason for this examination: eval for recurrent pes no contraindications for iv contrast ______________________________________________________________________________ final report indications: recent dvt/saddle embolus, massive hemoptysis. comparison was made to the chest ct from [**2141-12-18**]. technique: axial images of the chest were acquired helically with 100 cc of optiray contrast, per pe study protocol. there were no adverse reactions to contrast administration. findings: ct of the chest with iv contrast: there has been significant recanalization of the left pulmonary arterial system. residual filling defect is still present within segmental branches of the left lower and left middle lobe vessels. there is evidence of remodeling of the right pulmonary arterial thrombus as well. the right upper lobe and middle lobe segments are predominantly recannulated. blood flow has been reestablished to the basilar segments, as well, around intraluminal thrombus. there is consolidation within the right lower lobe and right middle lobe, which is nonspecific, and may represent pneumonic consolidation, or, less likely, areas of infarction. no significant hilar, mediastinal, or axillary lymphadenopathy is present. no pleural or pericardial effusions are present. impression: 1) extensive retraction and revascularization of previously-seen pulmonary emboli. 2) right lower lobe and right middle lobe consolidations, nonspecific, may represent pneumonia, or less likely, infarction.",0
438,"[**2151-12-28**] 9:24 am ct abd w&w/o c; ct 150cc nonionic contrast clip # [**clip number (radiology) 46177**] reason: hx resected gallbladder ca, eval for tumor recurrence, pt c/o bloating, cramping field of view: 40 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 69 year old woman with resected gallbladder ca reason for this examination: ? tumor recurrence itching use iv/po contrast no pelvis needed ______________________________________________________________________________ final report indication: resected gallbladder ca, ? tumor recurrence. comparison is made to the abdominal ct from [**2151-9-21**]. technique: axial images of the abdomen were acquired helically, before and after administration of 150 cc optiray contrast, in multiple phases. there were no adverse reactions to contrast administration. findings: ct of the abdomen with iv contrast: left basilar atelectasis is present. there is a large amount of residual oral barium within the stomach from prior upper gi study. the concentration of contrast creates significant beam hardening artifact, limiting the utility of this study. the stomach is distended with a fluid-fluid level from oral contrast and water. the gallbladder has been surgically removed. there is a residual biliary catheter from the common hepatic duct to the duodenum. there is increased soft tissue density adjacent to the distal stomach, which is highly suggestive of local recurrence. there is a new 14 x 23 mm focus of decreased attenuation within the liver parenchyma adjacent to the gallbladder fossa within segment 4b, which is also highly suggestive of neoplastic involvement. abnormal tissue planes are present anterior to the liver, which are also worrisome for neoplastic infiltration. the likely neoplastic involvement of the proximal duodenum is causing gastric outlet obstruction. numerous cysts are present within the right kidney. evaluation of the left kidney is extremely limited due to beam hardening artifact. there is no ascites. impression: 1. large amount of oral barium from upper gi series limits evaluation. 2. findings suspicious for local recurrence in the gallbladder fossa, causing gastric outlet obstruction. region of likely metastasis vs. direct invasion of the liver, segment 4b. likely anterior abdominal wall neoplastic infiltration. (over) [**2151-12-28**] 9:24 am ct abd w&w/o c; ct 150cc nonionic contrast clip # [**clip number (radiology) 46177**] reason: hx resected gallbladder ca, eval for tumor recurrence, pt c/o bloating, cramping field of view: 40 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont)",0
439,"[**2167-1-8**] 8:38 am ct abdomen w/contrast clip # [**clip number (radiology) 77125**] reason: f/u on skiing accident, splenic laceration contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 17 year old man with reason for this examination: f/u on skiing accident, splenic laceration ______________________________________________________________________________ final report (revised) indication: prior splenic laceration on skiing accident. comparison: initial studies obtained at outside hospital, and not available for comparison at time of dictation. technique: axial images of the abdomen were acquired helically with 150 cc of optiray contrast. there were no adverse reactions to contrast. ct abdomen w/contrast: the lung bases are clear. no pleural or pericardial effusions are seen. changes are present within the spleen from prior splenic laceration. there is no fluid in the abdomen, and no hematoma adjacent to the spleen. these findings represent a stable splenic laceration, and no further follow-up is likely to be needed. no focal liver lesions are identified. the pancreas, adrenal glands, gallbladder, stomach and intra-abdominal loops of large and small bowel are within normal limits. the kidneys enhance symmetrically without evidence of mass or obstruction. there is no significant mesenteric or retroperitoneal lymphadenopathy. the osseous structures are unremarkable. impression: stable appearing changes from prior splenic laceration.",0
440,"[**2129-1-4**] 1:05 pm ct abd w&w/o c; ct pelvis w/contrast clip # [**clip number (radiology) 60838**] ct 150cc nonionic contrast reason: stomach (antral) adeno ca field of view: 38 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 2**] medical condition: 69 year old woman with reason for this examination: stomach (antral) adeno ca ______________________________________________________________________________ final report indication: stomach adenocarcinoma. no prior studies are available for comparison. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases through the pubic symphysis, before and after administration of 150 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: ct of the abdomen with iv contrast: dependent changes are see within the lung bases. no suspicious parenchymal nodules are seen. no focal liver lesions are identified. the spleen, pancreas, adrenal glands, and gallbladder are within normal limits. there is asymmetrical wall thickening of the distal gastric antrum consistent with the patient's provided history of gastric adenocarcinoma. numerous small lymph nodes are seen in the surrounding fat, the largest of which measures 6 mm. there is preservation of the fat plane between the abnormal gastric wall thickening and the pancreatic head. the margin between the stomach wall and the inferior aspect of the liver is less clearly visualized. there is no ascites. no significant retroperitoneal lymphadenopathy is present. the kidneys enhance symmetrically without evidence of focal mass or obstruction. the small bowel and intra- abdominal loops of large bowel are unremarkable. ct of the pelvis with iv contrast: the distal ureters, bladder, sigmoid colon, and rectum are within normal limits. there is a very round cystic structure within the uterus, which likely represents a degenerating fibroid. there is a 3.1 x 4.2 cm soft tissue density mass within the left adnexa. this may represent metastatic tissue or a primary ovarian abnormality. followup with pelvic ultrasound is recommended. there is no free fluid in the pelvis, and no significant pelvic or inguinal lymph adenopathy. no suspicious lytic or sclerotic osseous lesions are identified. numerous focal calcifications are demonstrated within both gluteal muscles, which likely represent injection granulomas. impression: 1. gastric antral wall thickening, with associated surrounding lymphadenopathy consistent with the provided history of antral adenocarcinoma. there is preservation of the fat plane between the stomach and the pancreas. (over) [**2129-1-4**] 1:05 pm ct abd w&w/o c; ct pelvis w/contrast clip # [**clip number (radiology) 60838**] ct 150cc nonionic contrast reason: stomach (antral) adeno ca field of view: 38 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) the fat plane between liver and stomach is not preserved, however this may be due to partial volume averaging. 2. soft tissue mass in the left adnexa this is concerning for metastatic disease and pelvic ultrasound is recommended for further evaluation. 3. submucosal fibroid within the uterus.",
441,"[**2193-3-13**] 5:28 pm ct chest w/contrast; ct 100cc non ionic contrast clip # [**clip number (radiology) 82166**] reason: assess for fluid collections/sources of infection contrast: optiray amt: 100 ______________________________________________________________________________ [**hospital 3**] medical condition: 81 year old man s/p cabg w/ erythematous/unstable sternum reason for this examination: assess for fluid collections/sources of infection no contraindications for iv contrast ______________________________________________________________________________ final report indications: erythematous and unstable sternum, assess for fluid collections/source of infection. comparison was made to the chest ct from [**2193-3-7**]. technique: axial images of the chest were acquired helically from the lung apices through the lung bases with 100 cc of optiray contrast. non-ionic contrast was used secondary to the patient's allergy history. there were no adverse reactions to contrast administration. findings: ct of the chest with iv contrast: numerous mediastinal lymph nodes are present which do not meet size criteria for pathological enlargement by ct. no pathologically-enlarged axillary or hilar lymph nodes are seen. the aorta is densely calcified, but is unchanged in appearance. bilateral pleural effusions are slightly larger, with an associated increase in the amount of bibasilar and lingular atelectasis. again identified are bilateral areas of calcified pleural plaque. no new pneumonic consolidations are present. the sternal fluid collection is essentially unchanged in size. it demonstrates less internal gas. also noted is intraabdominal fluid around the liver and spleen, which demonstrates hounsfield units below that of blood, and which was not present on the prior chest ct. impression: 1) increasing bilateral pleural effusions and atelectasis. no new pneumonic consolidations. 2) stable sternal fluid collection, with less internal air vs. prior. 3) new intraabdominal fluid, likely ascites by hounsfield units. these results were discussed with the internal medicine housestaff at the time of interpretation. (over) [**2193-3-13**] 5:28 pm ct chest w/contrast; ct 100cc non ionic contrast clip # [**clip number (radiology) 82166**] reason: assess for fluid collections/sources of infection contrast: optiray amt: 100 ______________________________________________________________________________ final report (cont)",0
442,"[**2143-3-19**] 5:42 pm cta chest w&w/o c &recons; ct 100cc non ionic contrast clip # [**clip number (radiology) 82258**] reason: hocm,pleural effusion,s/p thoracentesis revealing hemothorax,eval pe field of view: 30 contrast: optiray amt: 100 ______________________________________________________________________________ final report indication: thoracentesis revealed hemothorax. evaluate for pulmonary embolus. comparison is made to the chest cta from [**2143-3-6**]. technique: axial images of the chest were acquired helically with 100 cc of optiray contrast, per pe study protocol. there were no adverse reactions to contrast administration. findings: ct of the chest with iv contrast: the pulmonary vasculature is well opacified and demonstrates no intraluminal filling defect to suggest pulmonary embolus. the aorta is heavily calcified and demonstrates extensive mural plaque. there has been interval insertion of a left sided thoracotomy tube. the tip is near the ascending aorta. a small anterior pneumothorax is present, along with subcutaneous air. there has been a pronounced decrease in the size of the bilateral pleural effusions. there is left lower lobe and lingular atelectasis. no suspicious lytic or sclerotic osseous lesions are identified. impression: 1. no pulmonary embolus. 2. insertion of chest tube and decreasing in pleural effusion size. small anterior pneumothorax and subcutaneous air. 3. left lower lobe and lingula atelectasis.",0
443,"[**2131-4-10**] 4:28 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 32383**] ct 150cc nonionic contrast; ct reconstruction reason: pmh crohn's, malignant colonic polyps, sbo field of view: 38 contrast: optiray amt: 150 ______________________________________________________________________________ wet read: eez tue [**2131-4-10**] 4:59 pm thickening in terminal ileum and ascending colon. ascitic fluid around liver, spleen, and in pelvis. inflammatory changes in mesentery. no obstruction. ______________________________________________________________________________ final report indication: history of crohn's, evaluate for bowel obstruction. no prior abdominal cts are available for comparison. technique: axial images of the abdomen and pelvis were acquired helically, from the lung bases through the pubic symphasis, with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: ct of the abdomen with iv contrast: multiple areas of bibasilar atelectasis are present. no pleural or pericardial effusions are seen. a hiatal hernia is present. the liver demonstrates a nodular contour with ascites. the spleen is enlarged. this constellation of findings is consistent with portal hypertension, possibly from cirrhosis. the gallbladder, pancreas, adrenal glands, and stomach are unremarkable. the kidneys enhance symmetrically without evidence of focal mass or obstruction. there is no pathological retroperitoneal lymphadenopathy. there is some nonspecific soft-tissue density thickening adjacent to the celiac and mesenteric arterial axes, which is of unknown significance. there are multiple areas of small bowel wall thickening. the terminal ileum is thickened. there is a marked area of small bowel wall thickening in the mid abdomen with narrowing of the lumen, however there is no evidence for obstruction, as contrast passes freely into the rectum. there is significant mesenteric fat stranding and inflammatory changes in these areas. findings are consistent with the patient's known crohn's disease. ct of the pelvis with iv contrast: a moderately large amount of free fluid is present in the pelvis. the cecum is redundant. again, there are inflammatory changes in the terminal ileum consistent with crohn's disease. there is an ascitic fluid-containing right inguinal hernia. distal ureters and bladder are unremarkable. the rectum is unremarkable, demonstrating peristalsis. no suspicious lytic or sclerotic osseous lesions are identified. impression: 1) multiple areas of small bowel wall thickening and associated mesenteric stranding, likely from the patient's known crohn's disease. prominent areas are in the terminal ileum, and jejunum. 2) nodular liver contour with ascites and splenomegaly, findings consistent (over) [**2131-4-10**] 4:28 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 32383**] ct 150cc nonionic contrast; ct reconstruction reason: pmh crohn's, malignant colonic polyps, sbo field of view: 38 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) with portal hypertension and cirrhosis. 3) soft-tissue thickening adjacent to celiac and superior mesenteric arterial axes without evidence for a mass and therefore, of unknown clinical significance. follow- up ct in 6 months could be considered.",0
444,"[**2107-4-18**] 7:52 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 101356**] ct 150cc nonionic contrast; ct reconstruction reason: j tube replacement and sharp llq pain, fevers, elevated inr, field of view: 32 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 3**] medical condition: 31 year old woman with j tube displacement replaced today by ir with abd pain reason for this examination: j tube replacement and sharp llq pain, fevers, elevated inr, please eval for abscess, sheath hematoma no contraindications for iv contrast ______________________________________________________________________________ wet read: eez mon [**2107-4-18**] 8:51 pm no abscess/hematoma. appearance unchanged since [**2107-3-3**]. ______________________________________________________________________________ final report indications: left lower quadrant pain, fevers and elevated inr, evaluate for abscess or hematoma. comparison was made to the abdomen ct from [**2107-3-3**]. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases through the pubic symphysis with 150 cc of optiray contrast. non-ionic contrast was used secondary to the patient's allergy history. there were no adverse reactions to contrast administration. coronal reformations were made. findings: ct of the abdomen with iv contrast: minimal dependent changes are seen within the lung bases. again visualized anterior to the heart is a loop of large bowel. an additional fluid-filled structure is present posterior to the colonic loop, which is also contiguous with bowel. overall appearance is unchanged since the patient's prior study, and likely represents post surgical changes. no focal liver lesions are identified. the gallbladder, spleen, pancreas, adrenal glands, kidneys, and stomach are unremarkable. there is no ascites. no abdominal fluid collections are present to suggest abscess or hematoma. there is no evidence of obstruction. there is no pathological mesenteric or retroperitoneal lymphadenopathy. no free intraperitoneal air. ct of the pelvis with iv contrast: a jejunostomy tube is present within the mid left pelvis. there is no inflammatory change, abscess, or hematoma adjacent to the jejunostomy tract. the jejunal loop is unremarkable. there is no free intraperitoneal or intrapelvic air. no free fluid is present in the pelvis. the uterus is bulky, but is within normal limits. the ovaries are unremarkable. no pathological pelvic or inguinal lymphadenopathy. no suspicious lytic or sclerotic osseous lesions are identified. impression: 1) multiple loops of bowel anterior to heart, likely related to prior (over) [**2107-4-18**] 7:52 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 101356**] ct 150cc nonionic contrast; ct reconstruction reason: j tube replacement and sharp llq pain, fevers, elevated inr, field of view: 32 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) surgeries, and unchanged in appearance. 2) jejunostomy tube in place in mid left pelvis. no associated hematoma, abscess, or free intraperitoneal air. 3) overall appearance unchanged, with no acute intraabdominal abnormality, in comparison to the [**2107-3-3**] study. these results were discussed with the ed housestaff at the time of dication.",0
445,"[**2141-2-19**] 2:28 am cta chest w&w/o c &recons; ct 100cc non ionic contrast clip # [**clip number (radiology) 75542**] reason: pleuritic cp and sob, hx hepatoma with lung met, r/o pe field of view: 43 contrast: optiray amt: 100 ______________________________________________________________________________ [**hospital 2**] medical condition: 48 year old man with metastatic hepatoma reason for this examination: pleuritic cp and sob hx hepatoma with lung met r/o pe no contraindications for iv contrast ______________________________________________________________________________ wet read: eez sun [**2141-2-19**] 4:27 am pulmonary emboli in lingular branch and also likely in a left lower lobe branch ______________________________________________________________________________ final report *abnormal! indication: metastatic hepatoma with pleuritic chest pain and shortness of breath. evaluate for pulmonary embolus. no prior chest cts are available for comparison. technique: axial images of the chest were aquired helically from the lung apices to the lung bases with 100 cc of optiray contrast, per pe cta protocol. there were no adverse reactions to contrast administration. findings: the pulmonary vasculature is well opacified. the right sided pulmonary vasculature demonstrates no intraluminal filling defects. within the left are multiple segmental and subsegmental filling defects which represent pulmonary emboli. also noted are multiple bilateral lung parenchymal and mediastinal masses consistent with the patient's known metastatic hepatoma. there is obstruction of the left lower lobe bronchus with resultant atelectasis. left sided pleural thickening is also present posteriorly. an infectious process in the left lower lobe cannot be excluded. no susppicious lytic or sclerotic osseous lesions are identified. the visualized portions of the abdomen show liver defect from partial resection. impression: 1) multiple segmental and subsegmental left sided pulmonary emboli. 2) nodular lung parenchymal and mediastinal masses consistent with patient's known metastatic disease. 3) occlusion of left lower lobe bronchus with associated atelectasis. superimposed infectious process cannot be excluded. these results were discussed with the emergency department attending physician at the time of interpretation. (over) [**2141-2-19**] 2:28 am cta chest w&w/o c &recons; ct 100cc non ionic contrast clip # [**clip number (radiology) 75542**] reason: pleuritic cp and sob, hx hepatoma with lung met, r/o pe field of view: 43 contrast: optiray amt: 100 ______________________________________________________________________________ final report *abnormal! (cont)",0
446,"[**2184-3-2**] 2:44 am cta chest w&w/o c &recons; ct 100cc non ionic contrast clip # [**clip number (radiology) 36561**] reason: breast ca/sob field of view: 36 contrast: optiray amt: 100 ______________________________________________________________________________ [**hospital 2**] medical condition: 63 year old woman with breast cancer s/p lumpectomy, xrt, chemotherapy with local recurrance and sob and tachycardia reason for this examination: r/o pe no contraindications for iv contrast ______________________________________________________________________________ wet read: eez tue [**2184-3-2**] 3:24 am pulmonary embolus present. ______________________________________________________________________________ final report *abnormal! indications: breast cancer with local recurrence. new sob and tachycardia for pulmonary embolus. comparison is made to the chest ct from [**2184-2-6**]. technique: axial images of the chest were acquired helically from the lung apices to the lung bases with 100 cc of optiray contrast, per pe cta protocol. there were no adverse reactions to contrast administration. findings: ct chest with iv contrast; the pulmonary vasculature is well opacified. segmental and subsegmental pulmonary emboli are present in the left upper lobe pulmonary vasculature. there is a massive right pleural effusion with associated compressive atelectasis of almost the entire right lung. portions of the collapse lung are tethered to the thoracic wall, indicating this effusion is likely loculated. this effusion also causes leftward shift of mediastinal contents, raising the possibility that this fluid is under pressure. a small pericardial effusion is also present. the left lung is relatively clear with the exception of some patchy areas of atelectasis. there is a focus of decreased attenuation within the left medial lobe of the liver, which is not fully evaluated on this study. numerous pathologically enlarged left axillary lymph nodes are present. impression: 1. massive right sided likely loculated pleural effusion, causing near complete collapse of the right lung and leftward shift of the mediastinal contents, indicating that the fluid is likely under tension. 2. segmental and subsegmental pulmonary emboli to the left upper lobe. 3. pathologically enlarged left axillary lymph nodes. these results were discussed with the clinical housestaff at the time of interpretation. (over) [**2184-3-2**] 2:44 am cta chest w&w/o c &recons; ct 100cc non ionic contrast clip # [**clip number (radiology) 36561**] reason: breast ca/sob field of view: 36 contrast: optiray amt: 100 ______________________________________________________________________________ final report *abnormal! (cont)",0
447,"[**2128-3-22**] 8:27 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 83747**] ct 150cc nonionic contrast reason: fall from 2nd story balcony field of view: 33 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 20 year old man with reason for this examination: fall from 2nd story balcony no contraindications for iv contrast ______________________________________________________________________________ wet read: eez mon [**2128-3-22**] 9:17 pm no solid organ injury. no free fluid. no free air. ______________________________________________________________________________ final report indication: s/p fall from 2nd storey balcony. comparison: no prior abdominal ct available for comparison. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases through the pubic symphysis, with 150 cc of optiray contrast. there are no adverse reactions to contrast administration. findings: ct abdomen with iv contrast: there is atelectasis/consolidation in the left lung base, with a patchy area of atelectasis in the right lung base as well. no hepatic lacerations are present. there is distention of the ivc and bands of periportal decreased attenuation, consistent with aggressive fluid resuscitation. no splenic lacerations are present. the pancreas and duodenum are unremarkable. no renal lacerations are present. the kidneys enhance symmetrically without evidence of obstruction. the gallbladder, adrenal glands, stomach, and intraabdominal loops of small and large bowel are unremarkable. there is no free intraabdominal fluid and no pathologically enlarged mesenteric or retroperitoneal lymph nodes. ct pelvis with iv contrast: there is no free fluid in the pelvis. the sigmoid colon, rectum, and cecum are unremarkable. the distal ureters and bladder are within normal limits. no pathologically enlarged inguinal or pelvic lymph nodes are seen. osseous structures are unremarkable. no fractures are seen. impression: no solid organ injury. no free fluid and no free intraperitoneal air. no fractures. these results were discussed with the trauma team at the time of interpretation. (over) [**2128-3-22**] 8:27 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 83747**] ct 150cc nonionic contrast reason: fall from 2nd story balcony field of view: 33 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont)",0
448,"[**2184-3-23**] 9:51 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 73045**] ct 150cc nonionic contrast reason: s/p fall from stairs field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 84 year old man with reason for this examination: s/p fall from stairs no contraindications for iv contrast ______________________________________________________________________________ wet read: eez tue [**2184-3-23**] 10:29 pm no aortic/hepatic/splenic/renal injury. ______________________________________________________________________________ final report indication: fell down 16 stairs. no prior abdominal cts are available for comparison. technique: axial images of the abdomen and pelvis were aquired helically from the lung bases through pubic symphysis, with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: ct abdomen with iv contrast: patchy areas of atelectasis are present within both lung bases. no focal liver lesions are identified. no perihepatic hematoma is present. the spleen contains multiple calcified granulomas, but is otherwise unremarkable without evidence of laceration or surrounding hematoma. the pancreas and duodenum are within normal limits. the kidneys enhance symmetrically without evidence of laceration. a likely simple cyst is present in the inferior pole of the left kidney. abdominal aorta is normal in course and caliber but demonstrates extensive mural plaquing and calcification. there is no evidence of dissection. the adrenal glands, stomach, and gallbladder are unremarkable. small bowel loops are within normal limits, without mesenteric fluid collections or dilation. intraabdominal loops of large bowel are also unremarkable. there is no ascites. no pathologically enlarged mesenteric or retroperitoneal lymph nodes are seen. ct pelvis with iv contrast: the sigmoid colon, rectum, distal ureters, and bladder are unremarkable. there is no free fluid in the pelvis and no pathologically enlarged pelvic or inguinal lymph nodes. osseous structures: there is deformity of the left femoral head, which has the appearance of remote trauma. no acute fractures are seen in the femurs or pelvis. multilevel degenerative changes are present within the spine. no definite rib fractures are seen. impression: no trauma related intraabdominal injuries seen. extensive mural plaques and calcification of the abdominal aorta. these results were discussed with the emergency department house staff at the (over) [**2184-3-23**] 9:51 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 73045**] ct 150cc nonionic contrast reason: s/p fall from stairs field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) time of interpretation.",0
449,"[**2110-4-6**] 1:19 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 85220**] ct 150cc nonionic contrast reason: ct of abd/pelvis with po and iv contrast field of view: 40 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 2**] medical condition: 46 year old man s/p hepatojej for cbd stricture, now with tender abdomen. prior ct with hematoma. now with increased abd pain and fever. reason for this examination: ct of abd/pelvis with po and iv contrast no contraindications for iv contrast ______________________________________________________________________________ final report indication: status post hepatojejunostomy for cbd stricture, now with tender abdomen and fever, also has prior hematoma. comparison is made to the abdomen/pelvis ct from [**2110-4-1**]. technique: axial images of the abdomen and pelvis were acquired helically, with 150 cc of optiray contrast. optiray was used secondary to the patient's debility history. there are no adverse reactions to contrast administration. findings: ct of the abdomen with iv contrast: bibasilar atelectasis is present. no paracardial effusions are present. again seen is air within the left hepatic biliary system, which is unchanged in appearance. no focal liver lesions are identified. the spleen, pancreas, adrenal glands, kidneys, and stomach are unremarkable. the previously seen fluid collection adjacent to the duodenum is not as clearly visualized on today's study. located immediately inferior to the liver is a complex fluid collection which demonstrates gas and heterogeneous internal debris. this is located in the region of the patient's suspected prior hematoma. a large amount of fat stranding is present adjacent to this collection. the findings are extremely suggestive of an abscess. part of this fluid collection is intimately associated with the wall of the ascending colon. ct of the pelvis with iv contrast: again seen is a intrapelvic fluid collection with houndsfield units greater than that of water. the size and density of this fluid collection has not significantly changed since the [**2110-4-1**] study, and likely represents blood products. the distal ureters, bladder, sigmoid colon, and rectum are unchanged in appearance. impression: 1) largee abscess in right abdomen. 2) stable pelvic fluid collection. these results were discussed with dr. [**first name8 (namepattern2) 85221**] [**last name (namepattern1) 2764**], at the time of interpretation. (over) [**2110-4-6**] 1:19 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 85220**] ct 150cc nonionic contrast reason: ct of abd/pelvis with po and iv contrast field of view: 40 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont)",0
450,"[**2130-5-13**] 12:23 am ct abd w&w/o c; ct pelvis w/contrast clip # [**clip number (radiology) 84814**] ct 150cc nonionic contrast reason: assess for free air, pneumobilia contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 45 year old man with hx of diabetes type ii, chronic pancreatitis, s/p ercp [**5-11**] with bx and stent placement. p/w n/v, abd pain, wbc 18. reason for this examination: assess for free air, pneumobilia no contraindications for iv contrast ______________________________________________________________________________ wet read: eez sat [**2130-5-13**] 4:19 am likely acute hemorrhage into pancreatic head mass ______________________________________________________________________________ final report *abnormal! indication: elevated white count, recent ercp, evaluate for free air and pneumobilia. comparison is made to the abdominal ct from [**2130-5-3**]. technique: axial images of the abdomen and pelvis were aquired helically from the lung bases through the pubic symphysis before and after administration of 150 cc of optiray conrast, in multiple phases. nonionic contrast was used per patient request. there were no adverse reactions to contrast administration. findings: ct abdomen with iv contrast: the lung bases are clear. no pleural or pericardial effusions are seen. no focal liver lesions are identified. again noted are diffuse intrahepatic biliary ductal dilatation. the amount of which, is unchanged. a biliary stent is seen traversing the common bile duct down into the duodenal bulb. again seen are chronic pancreatitis related calcifications throughout the pancreas. the previously described pancreatic head mass, which resembles a pseudocyst, has enlarged (5cm max diameter vs 2.5). the previously seen internal fluid contents within this pseudocyst are now heterogeneous and more dense, consistent with acute hemorrhage. on the arterial phase is a 5mm area of increased attenuation which increases on delayed imaging, and likely represents a focus of active bleed. this area is located near the anterior superior pancreatic-duodenal arcade branch of the gastroduodenal artery. there is stable dilatation of the pancreatic duct. the appearance of the spleen, adrenal glands, kidneys, and small bowel loops is unchanged. the portal vein, celiac artery, proper heaptic artery, splenic artery, and superior mesenteric vein remain patent. superior mesenteric artery and renal arteries are also patent. there is no ascites or pathologically enlarged mesenteric or retroperitoneal lymph nodes. ct pelvis with iv contrast: distal ureters, bladder, sigmoid colon and rectum are unremarkable. there is no free fluid in the pelvis or pathologically enlaged inguinal or pelvic nodes. (over) [**2130-5-13**] 12:23 am ct abd w&w/o c; ct pelvis w/contrast clip # [**clip number (radiology) 84814**] ct 150cc nonionic contrast reason: assess for free air, pneumobilia contrast: optiray amt: 150 ______________________________________________________________________________ final report *abnormal! (cont) osseous structures are stable in appearance. impression: 1) acute hemorrhage into pancreatic pseudocyst, indicative of formation of pseudoaneurysm. active bleeding is present. angiography is recommended to evaluate the area of active bleeding. 2) biliary stent placement with pneumobilia. these results were discussed with the clinical house staff and with the interventional radiology service at the time of interpretation.",0
451,"[**2109-3-1**] 10:13 pm cta chest w&w/o c &recons; ct abdomen w/contrast clip # [**clip number (radiology) 87764**] ct abdomen w/contrast; ct reconstruction reason: s/p mva with upper extremity fractures; ct chest with contra field of view: 42 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 58 year old man with reason for this examination: s/p mva with upper extremity fractures; ct chest with contrast, r/o vascular, pulmonary injury no contraindications for iv contrast ______________________________________________________________________________ wet read: eez fri [**2109-3-1**] 11:03 pm no aortic injury. no hepatic/splenic/pancreatic/duodenal/renal injury. no free fluid, no free air. right humeral head and clavicular fractures, subclavian vessels appear ok. wet read version #1 eez fri [**2109-3-1**] 11:02 pm no aortic injury. no hepatic/splenic/pancreatic/duodenal/renal injury. no free fluid, no free air. ______________________________________________________________________________ final report indication: status post mva, car vs tree. no prior ct scans are available for comparison. technique: axial images of the chest, abdomen and pelvis were aquired helically from the lung apices through the pubic symphysis with 150 cc of optiray conrast. there were no adverse reactions to contrast administration. findings: ct chest with iv contrast: there is no evidence of traumatic aortic injury. the aorta is of normal caliber and demonstrates no surrounding hematoma or active extravasation. the heart and great vessels are unremarkable. no pleural or pericardial effusions are seen. minimal dependent changes are seen within the lung bases. no pathologically enlarged axillary, hilar or mediastinal nodes are seen. no pneumothorax is present. ct abdomen with iv contrast: the liver enhances symmetrically without evidence of surrounding hematoma or laceration. the spleen is normal. pancreas and duodenum are unremarkable without evidence for traumatic injury. both kidneys enhance symmetrically without perinephric fluid or laceration. the gallbladder, adrenal glands, and intraabdominal loops of small bowel are unremarkable. no mesenteric fluid collection is seen. the celiac, superior, and inferior mesenteric arteries are unremarkable. the smv, splenic and portal veins are all patent. there is no ascites or free intraabdominal air. ct pelvis with iv contrast: distal ureters, bladder, and sigmoid colon are unremarkable. there is no free fluid in the pelvis. adjacent to the rectum is a dense oval calcific density which measures 13 mm in greatest dimension. this finding is of unknown etiology, but given the calcification, it is likely a chronic finding. there is no free fluid in the pelvis. within the cecum is (over) [**2109-3-1**] 10:13 pm cta chest w&w/o c &recons; ct abdomen w/contrast clip # [**clip number (radiology) 87764**] ct abdomen w/contrast; ct reconstruction reason: s/p mva with upper extremity fractures; ct chest with contra field of view: 42 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) an area of increased attenuation which may simply represent inspissated stool, but which has the appearance of a pedunculated polyp. no pathologically enlarged inguinal or pelvic nodes are seen. osseous structures: there is a fracture of the right humeral head which is comminuted with impaction of the distal fracture fragment. the fragmented humeral head is articulating within the glenoid fossa. a comminuted, but nondisplaced fracture of the right clavicle is also present. there is widening of the right sternoclavicular joint. the underling subclavian vessels are patent, without evidence of surrounding hematoma. no scapular fracture is seen. there are deformities of multiple ribs anteriorly, bilaterally, suggestive of traumatic injury. degenerative changes are seen throughout the spine. no pelvic fractures are seen. visualized portions of the proximal femurs are normal. impression: 1) no evidence of acute aortic or intraabdominal injury. 2) comminuted fracture of right humeral head. 3) comminuted nondisplaced fracture of the right clavicle and widening of sternoclavicular joint. subclavian vessels intact. 4) multiple bilateral anterior rib deformities suggestive of acute trauma. 5) possible cecal polyp vs stool. given morphology seen, follow-up with appropriately prepared ct colonoscopy or conventionial colonoscopy is recommended.",0
452,"[**2131-5-18**] 7:49 am ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 23156**] ct 150cc nonionic contrast reason: s/p mvc with mental status change. eval for solid organ inju field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 45 year old man s/p mvc. reason for this examination: s/p mvc with mental status change. eval for solid organ injury. no contraindications for iv contrast ______________________________________________________________________________ wet read: eez fri [**2131-5-18**] 9:45 am no acute intra-abominal injury. ______________________________________________________________________________ final report indication: status post mvc, evaluate for solid abdominal organ injury. technique: axial images of the abdomen and pelvis were aquired helically from the lung bases to the pubic symphysis with 150 cc of nonionic contrast. there were no adverse reactions to contrast adminisration. findings: ct of the abdomen with iv contrast: minimal dependent changes are seen within the lung bases. no pleural or pericardial effusions are seen. no hepatic or splenic lacerations are present. there is no free intra-abdominal fluid. small bowel loops are normal in caliber and demonstrate normal wall thickness. the duodenum and pancreas are unremarkable. the mesentary is normal. the kidneys enhance symmetrically without evidence of perinephric fluid collections. there is no free intra- abdominal air. no pathologically enlarged mesneteric or retroperitoneal lymph nodes are seen. ct of the pelvis with iv contrast: the distal ureters, bladder, sigmoid colon, rectum, and prosatee are unremarkable. there is no free fluid in the pelvis. or pathologically enlarged pelvic or inguinal nodes. no suspicious lytic or sclerotic osseous lesions are identified. no fractures are seen. impression: mo evidence of acute intra-abdominal injury. these results were discussed with the trauma team at the time of interpretation.",0
453,"[**2144-2-26**] 10:29 pm ct abd w&w/o c; ct pelvis w&w/o c clip # [**clip number (radiology) 80734**] ct 150cc nonionic contrast reason: necrotizing fachiitis, fever contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 3**] medical condition: 50 year old man with h/o nec fasc and now with fever and hypotension reason for this examination: r/o air no contraindications for iv contrast ______________________________________________________________________________ final report indication: purulent drainage from groin status post multiple flaps. comparison is made to the [**2144-1-15**] ct scan. technique: axial images of the abdomen, pelvis and proximal lower extremities were aquired helically from the lung bases through the knees, before and after administration of 150 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: ct abdomen with iv contrast: minimal dependent changes and atelectasis are seen within the lung bases. there is a focal area of decreased attenuation within the liver parenchyma adjacent to the falciform ligament which likely represents an area of focal fatty infiltration. the spleen, pancreas, adrenal glands, kidneys, gallbladder, stomach are unremarkable. again noted is a colostomy in the left lower quadrant. no intraabdominal fluid collections are present to suggest abscess. there is no ascites. scattered retroperitoneal lymph nodes are identified. ct pelvis with iv contrast: the bladder, sigmoid colon, and rectum are unremarkable. there is no free fluid in the pelvis, and no evidence of pelvic abscess. extensive changes are present from multiple prior flap surgeries. the right lateral abdominal wall flap demonstrates minimal adjacent stranding, but no evidence of fluid collection, enhancement, or gas to suggest abscess. the right testicle is visualized in the groin region, but the attenuation is different than on the prior study, possibly representing surrounding fluid. the left testicle is encased by the scrotal flap, which demonstrates a similar density to the right testicle, and minimal surrounding stranding. there is edema in the medial right thigh musculature underneath the flap resection area. no fluid collections are seen. there is no intramuscular or subcutaneous gas. impression: extensive changes from multiple flap surgeries with adjacent areas of subcutaneous edema and inflammatory stranding. edema in proximal right groin musculature in region of flap harvest. no evidence of abscess formation or subcutaneous air. ultrasound may be helpful for the evaluation of surface (over) [**2144-2-26**] 10:29 pm ct abd w&w/o c; ct pelvis w&w/o c clip # [**clip number (radiology) 80734**] ct 150cc nonionic contrast reason: necrotizing fachiitis, fever contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) fluid collections in the right groin and in the neo- scrotum.",0
454,"[**2140-4-20**] 12:25 am cta chest w&w/o c &recons; ct 100cc non ionic contrast clip # [**clip number (radiology) 83719**] reason: post-op hip fracture with l sided pleuritic chest pain, new field of view: 36 contrast: optiray amt: 100 ______________________________________________________________________________ [**hospital 2**] medical condition: 81 year old woman with see above reason for this examination: post-op hip fracture with l sided pleuritic chest pain, new hypoxemia; eval for pe no contraindications for iv contrast ______________________________________________________________________________ wet read: eez wed [**2140-4-20**] 1:47 am no pe ______________________________________________________________________________ final report indication: left sided pleuritic chest pain and hypoxia, post-op hip fracture, evaluate for pulmonary embolism. no prior chest cts available for comparison, comparison is made to chest radiograph from [**2140-4-19**]. technique: axial images of the chest were aquired helically with 100 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: ct chest with iv contrast: the pulmonary vasculature is well opacified and demonstrates no intraluminal filling defects suggestive of pulmonary embolism. coronary artery calcifications are present in the left main and left anterior descending coronary arteries. no pleural or pericardial effusions are present. numerous calcified granulomas are present throughout both lungs. two additional nodular areas are present adjacent to the major fissure on the right. dependent changes and atelectasis are present in the lungs. no pneumonic consolidations are present. the bronchi are patent to the subsegmental levels. scattered mediastinal lymph nodes are present which do not meet size criteria for pathological enlargement. no pathologicaly enlarged axillary or hilar nodes are present. osseous structures show mild degenerative changes, but no suspicious lytic or sclerotic lesions. the aorta is calcified. impression: 1) no evidence of pulmonary embolism. 2) multiple calcified granulomas in both lungs, two nodular areas adjacent to the right major fissure, findings consistent with prior granulomatous infection. 3) aortic and coronary arterial calcifications. (over) [**2140-4-20**] 12:25 am cta chest w&w/o c &recons; ct 100cc non ionic contrast clip # [**clip number (radiology) 83719**] reason: post-op hip fracture with l sided pleuritic chest pain, new field of view: 36 contrast: optiray amt: 100 ______________________________________________________________________________ final report (cont)",0
455,"[**2184-2-18**] 12:33 am cta chest w&w/o c &recons; cta abd w&w/o c & recons clip # [**clip number (radiology) 88873**] cta pelvis w&w/o c & recons; ct 150cc nonionic contrast reason: 87 m h/o type b extensive aaa now with acute sob. field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 86 year old man with known extensive aaa, r/o progression / extravasation. reason for this examination: 87 m h/o type b extensive aaa now with acute sob. no contraindications for iv contrast ______________________________________________________________________________ wet read: eez wed [**2184-2-18**] 1:07 am dissection unchanged. no active extravasation. left pleural effusion, not blood products by houndsfield units. ______________________________________________________________________________ final report *abnormal! indication: history of type b aortic dissection, now presents with acute shortness of breath and hypotension. comparison is made with the torso ct from [**2184-2-12**] technique: axial images of the chest, abdomen and pelvis were aquired helically from the lung apices through the iliac bifurcation with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: ct chest with iv contrast: again demonstrated is an extensive class-b aortic dissection. there are extensive fenestrations between the two channels. the overall appearance is unchanged. the celiac axis, sma, left renal artery, and inferior mesenteric artery all originate from the true lumen. the right renal arteries likely do as well. there is no evidence of acute extravasation or surrounding hematoma. noted in the proximal descending aorta near the origin of the dissection is an area of iv contrast within the mural thrombus posteriorly. this is not in connection with the false lumen, but is likely related to the existing dissection. this area is located distal to the left subclavian artery, and was also present on the patient's prior study. a new left sided pleural effusion is present. this fluid has the density of [**4-1**] hounsfield units, which is below that of blood. it is associated with minor compressive atelectasis in the left lung base. a small right sided pleural effusion is also present. the pulmonary vasculature is well opacified and demonstrates no large central pulmonary emboli. no pericardial effusions are present. bibasilar atelectasis is present. no pneumonic consolidations are present. ct abdomen with iv contrast: the appearance of the liver, spleen, pancreas, adrenal glands, stomach, and intraabdominal loops of small and large bowel are unchanged. again demonstrated are gallstones in the gallbladder without evidence of acute cholecystitis. the kidneys enhance symmetrically. there is no ascites or pathologically enlarged mesenteric or retroperitoneal lymph nodes. (over) [**2184-2-18**] 12:33 am cta chest w&w/o c &recons; cta abd w&w/o c & recons clip # [**clip number (radiology) 88873**] cta pelvis w&w/o c & recons; ct 150cc nonionic contrast reason: 87 m h/o type b extensive aaa now with acute sob. field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ final report *abnormal! (cont) the abdominal aorta is of normal caliber. the dissection propigates all the way through the abdominal aorta into the right common iliac vessel, as on the prior study. ct pelvis with iv contrast: the bladder contains multiple calculi. this area was not imaged on the prior study. the sigmoid colon, rectum, and appendix are unremarkable. there is no free fluid in the pelvis or pathologically enlarged inguinal or pelvic nodes. osseous structures are stable in appearance. impression: 1) stable class b aortic aneurysm. both true and flase lumens still opacify. there has been no cranial progression of the aneurysm. there is no evidence of acute extravasation. 2) bilateral pleural effusions, left greater than right, associated with bibasilar atelectasis. attenuation values of the fluid are less than that of blood products. 3) calculi within the bladder. these results were discussed with the e.d. housestaff at the time of interpretation.",0
456,"[**2184-2-12**] 5:08 pm cta chest w&w/o c &recons; cta abd w&w/o c & recons clip # [**clip number (radiology) 88828**] cta pelvis w&w/o c & recons; ct 150cc nonionic contrast reason: r/o dissection contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 86 year old man with sudden onset of severe back pain on [**2-11**]. admitted to osh. non-contrast abdominal ct showing abdominal aortic dissection. request ct scan of chest and abdomen to evaluate for dissection reason for this examination: r/o dissection no contraindications for iv contrast ______________________________________________________________________________ final report indications: sudden onset of severe back pain, non-contrast ct scan at outside hospital suspicious for dissection. no prior ct scans are available for comparison. technique: axial images of the chest, abdomen and pelvis were acquired helically from the lung apices through the mid pelvis with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: ct of the chest with iv contrast: arising at the level of the distal aortic arch, and throughout the entire descending aorta is a dissection, with extensive fenestrations between the true and false lumens. the true and false lumens change position as the disection moves inferiorly. both are fully opacified shortly after the aortic arch. the left renal artery is patent and is supplied by the true lumen. there is likely extension of the dissection into the right renal artery, but the kidneys enhance symmetrically. the celiac, superior mesenteric, and inferior mesenteric arteries are all patent. the dissection extends into the right common iliac up to approximately the level of the iliac bifurcation. there is extensive calcification and tortuosity of the thoracic and abdominal aorta. there is no active extravasation or paraaortic hematoma. there is no extension into the brachiocephalic, left common carotid or left subclavian vessels. dependent changes and atelectasis are seen within the lung bases. there is a faint nodular opacity in the right middle lobe which measures 8 mm in greatest dimension. future follow-up for this nodule is warranted on follow-up imaging studies. no pleural or pericardial effusions are seen. extensive coronary arterial calcifications are present. no pathologically enlarged axillary, hilar, or mediastinal nodes are seen. ct of the abdomen with iv contrast: no focal liver lesions are identified. numerous calcified gallstones are present within the gallbladder. numerous small focal areas of decreased attenuation are present within the spleen. the pancreas, adrenal glands, stomach, and intraabdominal loops of small and large bowel are unremarkable without evidence of wall thickening. the kidneys enhance symmetrically. there is a simple cyst in the lower pole of the right (over) [**2184-2-12**] 5:08 pm cta chest w&w/o c &recons; cta abd w&w/o c & recons clip # [**clip number (radiology) 88828**] cta pelvis w&w/o c & recons; ct 150cc nonionic contrast reason: r/o dissection contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) kidney. there is no evidence of obstruction. there is no ascites or pathologically-enlarged mesenteric or retroperitoneal lymph nodes. ct of the pelvis with iv contrast: limited images through the pelvis show the termination of the aortic dissection as described above. there is no free fluid in the visualized portions of the pelvis. descending colon is unremarkable. both the internal and external iliac vessels are patent bilaterally. impression: extensive dissection of the descending thoracic aorta (class b). both true and false lumens well opacified. left renal artery, celiac artery, superior mesenteric artery, and inferior mesenteric artery are patent. there is probable extension into the right renal artery, but the kidneys enhance symmetrically. right middle lobe lung nodule, as described above. these results were discussed with dr. [**first name8 (namepattern2) 431**] [**last name (namepattern1) 6871**] at the time of interpretation, immediately.",0
457,"[**2175-4-14**] 1:13 pm ct abd w&w/o c; ct pelvis w/contrast clip # [**clip number (radiology) 81989**] reason: please eval for pancreatitis or pseudocyst contrast: optiray amt: ______________________________________________________________________________ [**hospital 4**] medical condition: 46 year old man with known necrotizing pancreatitis [**2-20**] p/w increased abd pain, low grade fever. reason for this examination: please eval for pancreatitis or pseudocyst no contraindications for iv contrast ______________________________________________________________________________ wet read: eez fri [**2175-4-14**] 3:49 pm stable peri-pancreatic fluid collections, likely developing into pseudocysts. ______________________________________________________________________________ final report *abnormal! indication: necrotizing pancreatitis in [**2175-2-18**], now with increasing abdominal pain and low grade fevers evaluate for pancreatitis or pseudocyst. comparison is made with the abdominal ct from [**2175-3-20**]. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases to the pubic symphysis, before and after administration of 150 cc of optiray contrast. non-ionic contrast was used secondary to patient debility. there were no adverse reactions to contrast administration. findings: ct of the abdomen with iv contrast: again identified is a small left-sided pleural effusion, which is decreased in size since the prior study. areas of atelectasis are present within both lung bases. no pericardial effusion is seen. no focal liver lesions are identified. the gallbladder, adrenal glands, kidneys, spleen, and intra-abdominal loops of small and large bowel are unremarkable. there is no free interperitoneal air. again identified are large fluid collections adjacent to the pancreas. there is extensive fat stranding throughout the mid-abdomen. lack of normal enhancement within the head and neck of the pancreas is likely due to necrosis, which is stable in appearance. the overall size of the fluid collections has not changed significantly. a thin enhancing wall is noted around the fluid collection anterior to the pancreas, which is suggestive of pseudocyst formation. in comparison to the prior study, there is increased stranding within the left upper quadrant in the region of the gastrocolic and splenocolic ligaments. there is no evidence of pseudoaneurysm. the portal vein is compressed, but is patent. the celiac and sma are patent. there is a stable amount of intra- abdominal and pelvic ascites. ct of the pelvis with iv contrast: the distal ureters, bladder, sigmoid colon, and rectum are unremarkable. there is a moderate sized fluid collection in the pelvis which is stable. no suspicious lytic or sclerotic osseous lesions are identified. (over) [**2175-4-14**] 1:13 pm ct abd w&w/o c; ct pelvis w/contrast clip # [**clip number (radiology) 81989**] reason: please eval for pancreatitis or pseudocyst contrast: optiray amt: ______________________________________________________________________________ final report *abnormal! (cont) impression: stable fluid collections adjacent to pancreas, likely developing into pseudocysts. there is increased stranding in the left upper quadrant along the gastrocolic and splenocolic ligaments, which may reflect superimposed acute pancreatitis. small left pleural effusion, decreased since the prior study. these results were discussed with the emergency department house staff at the time of interpretation.",0
458,"[**2153-2-11**] 10:20 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 75270**] ct 150cc nonionic contrast reason: expanding lt. groin hematoma field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 2**] medical condition: 66 year old woman with h/o large retroperitoneal bleed and l rectus sheath bleed s/p afib ablation now with severe abd pain, now with continued back pain reason for this examination: assess for retroperitoneal in bleed in 67 yo female w/ expanding l groin hematoma. please assess for evidence of active bleeding. [**first name8 (namepattern2) **] [**doctor last name 2163**] c [**numeric identifier 4527**] no contraindications for iv contrast ______________________________________________________________________________ final report indication: expanding left groin hematoma. comparison studies are not available for immediate comparison due to pacs malfunction. reference was made to measurements from the report. technique: axial images of the abdomen and pelvis were aquired helically from the lung bases through the pubic symphysis with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. additional three miniute delayed images were obtained. findings: ct abdomen with iv contrast: dependent changes and linear areas of atelectasis/scarring are present in the lung bases. no focal liver lesions are identified. the spleen, pancreas, adrenal glands, stomach, and intraabdominal loops of small and large bowel are unremarkable. there is no mesenteric or retroperitoneal lymphadenopathy, and no ascites. the kidneys enhance symmetrically without evidence of focal mass or obstruction. no retroperitoneal blood is seen in the abdomen. ct pelvis with iv contrast: again identified is a large left rectus sheath hematoma, and a liquifying hematoma in the space of retzius. this hematoma displaces the bladder laterally to the right. on the initial phase images, there is an area of dense contrast present within the central area of the hematoma, which spreads out on the three minute delayed images. these findings are consistent with an acute bleed into the hematoma from the external iliac vessel. the largest dimensions of the hematoma on today's study are 6.9 x 9.8 cm, which by report, has increased in size. there is no free fluid in the pelvis. distal ureters, bladder, sigmoid colon, and rectum are unremarkable. no pathologically enlarged inguinal or pelvic lymph nodes are seen. no suspicious lytic or sclerotic osseous lesions are identified. impression: interval increase in size of left rectus sheath hematoma with evidence of active bleeding within the hematoma. these results were discussed immediately with the clinical house staff and (over) [**2153-2-11**] 10:20 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 75270**] ct 150cc nonionic contrast reason: expanding lt. groin hematoma field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) with the emergency department house staff.",0
459,"[**2184-2-22**] 4:55 am ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 88728**] ct 150cc nonionic contrast; ct reconstruction reason: r/o intraabdominal obstruction/abscess field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 56 year old woman with hx of ulcerative colitis, pneumocystis carnii, on steroids, hypotensive, febrile reason for this examination: r/o intraabdominal obstruction/abscess no contraindications for iv contrast ______________________________________________________________________________ final report indication: ulcerative colitis. pcp on steroids. hypotensive and febrile. evaluate for abscess. no prior abdominal ct's are available for comparison. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases to pubic symphysis with 150 cc optiray contrast. there were no adverse reactions to contrast. ct abdomen w/contrast: there is extensive consolidation and ground glass opacity within both lungs, consistent with pcp. [**name10 (nameis) **] focal liver lesions are identified. the gallbladder, spleen, pancreas, adrenal glands, kidneys, stomach and intra-abdominal loops of large and small bowel are unremarkable. there is no ascites or pathologically enlarged mesenteric or retroperitoneal lymph nodes. ct pelvis w/contrast: the distal ureters and bladder, sigmoid colon and rectum are unremarkable. there is a small amount of free fluid in the pelvis. there is no evidence of abscess. there is no evidence of appendicitis or free intraperitoneal air. no suspicious lytic or sclerotic osseous lesions are identified. there is extensive subcutanous edema. impression: 1) extensive consolidation and ground glass opacity in the lung bases, consistent with pneumocystis carinii pneumonia. 2) no evidence of intra-abdominal abscess. a small amount of free fluid in the pelvis. 3) extensive subcutaneous edema. (over) [**2184-2-22**] 4:55 am ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 88728**] ct 150cc nonionic contrast; ct reconstruction reason: r/o intraabdominal obstruction/abscess field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont)",0
460,"[**2106-2-27**] 9:04 pm ct chest w/contrast; ct abdomen w/contrast clip # [**clip number (radiology) 66508**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: fevers of unknown source field of view: 39 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 2**] medical condition: [**age over 90 **] year old woman with as, chf, on mechanical ventilation with persistent fevers, unknown source reason for this examination: abscess no contraindications for iv contrast ______________________________________________________________________________ final report indication: persistent fevers. evaluate for abscess. comparison is made to ct from [**2106-2-16**]. technique: axial images were through the chest, abdomen and pelvis were acquired helically from the lung apices through the pubic symphysis with 150 cc of optiray contrast. non-ionic contrast was used secondary to patient's debility. there were no adverse reactions to contrast. ct chest w/contrast: a left-sided chest tube is present with the tip in the posterior costophrenic recess. a large, loculated, heterogeneous left-sided pleural effusion is present which contains internal air, suggestive of empyema. there is heterogeneous enhancement at the left lung base, which may represent blood products in the empyema. there is associated compressive atelectasis and tethering of the left lung. the size of the left- sided pleural effusion is essentially unchanged since [**2106-2-16**]. the previously seen right- sided effusion is decreased in size. there is consolidation in the right lower lobe and portions of the right upper and middle lobes. no pericardial effusion is present. the aorta and coronary arteries are calcified. no pathologically enlarged axillary, hilar or mediastinal lymph nodes are seen. ct abdomen w/contrast; no focal liver lesions are identified. the spleen, pancreas, adrenal glands, stomach and intra-abdominal loops of small and large bowel are unremarkable. there is no ascites. no pathologically enlarged mesenteric or retroperitoneal nodes are seen. the gallbladder is normal. no intra-abdominal fluid collections are present to suggest abscess. there is no free intra-abdominal air. there is mild cortical atrophy of the kidneys. the kidneys otherwise, enhances symmetrically without evidence of focal mass or obstruction. ct pelvis w/contrast: no fluid collections are seen in the pelvis. the sigmoid colon and rectum are within normal limits. no pathologically enlarged inguinal or pelvic nodes are seen. there is mild stranding seen in the right groin associated with the femoral venous catheter. bilateral compression screws are present within the femurs. there is extensive degenerative changes within the spine. changes from healed (over) [**2106-2-27**] 9:04 pm ct chest w/contrast; ct abdomen w/contrast clip # [**clip number (radiology) 66508**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: fevers of unknown source field of view: 39 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) bilateral pelvic fractures are present. no suspicious lytic or sclerotic osseous lesions are identified. impression: 1) loculated effusion with features suggestive of empyema in left lung. consider chest tube repositioning. 2) areas of consolidation in the right lower and right middle lobes, likely pneumonic. 3) no intra-abdominal fluid collections suspicious for abscess.",0
461,"[**2141-3-28**] 9:22 pm ct abdomen w/contrast; ct 150cc nonionic contrast clip # [**clip number (radiology) 91383**] ct pelvis w/contrast; ct reconstruction reason: small bowel obstruction, eval for location or abscess field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 3**] medical condition: 67 year old man with above reason for this examination: small bowel obstruction, eval for location or abscess no contraindications for iv contrast ______________________________________________________________________________ wet read: eez tue [**2141-3-28**] 10:03 pm parastomal hernia with dilated small bowel and colonic loop. no strangulation. transition point outside hernia sac but adjacent to it. ______________________________________________________________________________ final report indication: small bowel obstruction, parastomal hernia, evaluate for level, and evidence of abscess. technique: axial images of the abdomen and pelvis were aquired helically, with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. comparison is made to the [**2141-2-7**] torso ct. ct abdomen with iv contrast: within the lung bases are numerous pulmonary nodules, which have increased in number and conspicuity since [**2141-2-7**] study. a new focal lesion is present within the dome of the liver (segment 8) which measures 18 x 20 mm, and is suspicious for metastatic disease. a gallstone is present within the gallbladder. the adrenal glands, spleen, pancreas, and stomach are unremarkable. there is no ascites. no pathologically enlarged mesenteric or retroperitoneal lymph nodes are present. there is no ascites. again noted are hydronephrosis and delayed nephrogram of the right kidney, with stable hydroureter. again seen is a parastomal hernia, which now contains dilated loops of small bowel, and a collapsed colonic loop. numerous dilated small bowel loops are present within the abdomen. there is an apparent transitionzone located near, but not within, the hernial sac in the midline at approximately the level of l4. distal to this transition zone, the remaining small bowel loops and the entire colon is collapsed. the bowel wall within the hernial sac enhances uniformly, without evidence of ischemia. a small amount of fluid is present in the small bowel mesentery. ct pelvis with iv contrast: again seen is a large presacral mass, which is not changed significantly in size or appearance. there is hydronephrosis of the distal right ureter to the level of the presacral mass. the left ureter is unremarkable. the sigmoid colon is collapsed. osseous structures are stable in appearance. impression: 1) mechanical small bowel obstruction with transition zone in mid abdomen at (over) [**2141-3-28**] 9:22 pm ct abdomen w/contrast; ct 150cc nonionic contrast clip # [**clip number (radiology) 91383**] ct pelvis w/contrast; ct reconstruction reason: small bowel obstruction, eval for location or abscess field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) level of l4, outside patient's large parastomal hernia. 2) stable presacral mass. 3) progression of numerous pulmonary metastases. 4) new likely liver metastasis. 5) stable delayed right nephrogram, hydronephrosis, and hydroureter. these results were discussed with the surgical and emergency department house staff at the time of interpretation.",0
462,"[**2128-4-7**] 4:42 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 80880**] ct 150cc nonionic contrast reason: any intra-abd path ______________________________________________________________________________ [**hospital 4**] medical condition: 45 year old man with tac, endileostomy, fever spikes reason for this examination: any intra-abd path no contraindications for iv contrast ______________________________________________________________________________ final report indications: spiking fevers, post-op day 7 after abdominal operation. no prior studies are available for comparison. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases through the pubic symphysis with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: atelectasis is seen within the dependent portions of both lung bases. no focal liver lesions are identified. the spleen, pancreas, adrenal glands, and intraabdominal loops of small bowel are unremarkable. the stomach contains an ng tube. numerous surgical clips are present throughout the abdomen. there is a small collection of non-organized fluid adjacent to the inferior liver edge. no pathologically enlarged mesenteric or retroperitoneal nodes are seen. a tiny likely simple cyst is present in the mid portion of the left kidney. the kidneys otherwise enhance symmetrically without evidence of obstruction. the small bowel loops are normal in caliber. an ostomy is present in the right lower quadrant. ct of the pelvis with iv contrast: arising immediately adjacent to the rectal suture line is a pocket of fluid which demonstrates an enhancing rim and contains internal air. the pocket measures 3.6 x 7.0 cm. the air abuts the suture line. this fluid collection represents an abscess or a leak. the distal ureters, bladder, and remaining rectum are unremarkable. no pathologically- enlarged pelvic or inguinal nodes are seen. no suspicious lytic or sclerotic osseous lesions are identified. diffuse degenerative changes are seen in the spine. impression: fluid collection with enhancing rim and containing internal air, representing a leak or abscess. these results were discussed with the surgical housestaff at the time of interpretation.",0
463,"[**2141-2-10**] 11:53 pm cta abd w&w/o c & recons; cta pelvis w&w/o c & recons clip # [**clip number (radiology) 88772**] ct 150cc nonionic contrast reason: 68 yo man with aaa. r/o leak field of view: 42 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 69 year old man with reason for this examination: 68 yo man with aaa. r/o leak no contraindications for iv contrast ______________________________________________________________________________ wet read: eez sat [**2141-2-11**] 12:37 am no extravasation ______________________________________________________________________________ final report indicaation: abdominal aortic aneurysm, evaluate for rupture. technique: axial images of the abdomen and pelvis were aquired helically from the lung bases through the proximal femurs with 150 cc of optiray contrast. no adverse reaction to contrast administration. findings: ct abdomen with iv contrast: minimal dependent changes are seen in the lung bases. no focal liver lesions are identified. the gallbladder, spleen, pancreas, adrenal glands, stomach, and intraabdominal loops of small and large bowel are unremarkable. the kidneys enhance symmetrically. there is no evidence of obstruction. numerous bilateral simple renal cysts are present. there is a 6.4 cm infrarenal abdominal aortic aneurysm, which tapers as it enters the iliac bifurcation. there are areas of ulceratoin within the mural plaque. there is no evidence of hematoma or extravasation to suggest leak. minimal adjacent stranding is present, indicating inflammatory process. all major arterial branches are patent, including the inferior mesenteric artery and the renal arteries bilaterally. ct pelvis with iv contrast: the iliac vessels are normal in caliber by the level of the mid pelvis. sigmoid colon and rectum are normal. the bladder is unremarkable. no free fluid in the pelvis and no pathologically enlarged mesenteric or retroperitoneal lymph nodes are seen. no suspicious lytic or sclerotic osseous lesions are identified. impression: 6.4 cm infrarenal aortic aneurysm. no evidence of leak. minimal surrounding inflammatory changes. these findings were discussed with the surgical house staff at the time of interpretation. (over) [**2141-2-10**] 11:53 pm cta abd w&w/o c & recons; cta pelvis w&w/o c & recons clip # [**clip number (radiology) 88772**] ct 150cc nonionic contrast reason: 68 yo man with aaa. r/o leak field of view: 42 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont)",0
464,"[**2198-4-7**] 10:16 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 85117**] ct 150cc nonionic contrast; ct reconstruction reason: location/etiology of bowel obstruction field of view: 50 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 52 year old man with n/v, evidence of sbo on kub. reason for this examination: location/etiology of bowel obstruction no contraindications for iv contrast ______________________________________________________________________________ wet read: eez sat [**2198-4-7**] 11:00 pm findings suggestive of mechanical small bowel obstruction. ______________________________________________________________________________ final report (revised) indication: nausea vomiting evidence of small bowel obstruction on kub, evaluate for small bowel obstruction. reference is made to the patient's portable abdominal radiograph. technique: axial images of the abdomen and pelvis were acquired helically with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: ct of the abdomen with iv contrast: dependent changes are seen within both lung bases. additional patchy areas of opacity are present in both bases, left greater than right. a small left pleural effusion is present. no pericardial effusion is seen. numerous focal areas of decreased attenuation are present within the liver, which likely represent simple cysts. there is no biliary ductal dilatation. numerous surgical clips are present in the right upper quadrant from prior open cholecystectomy. an ng tube is present in the stomach. the spleen, and adrenal glands are unremarkable. the pancreas is atrophic and also contains numerous cystic areas near the uncinate process. innumerable cysts are seen within both kidneys, which enhance symmetrically without evidence of obstruction. the stomach is unremarkable. within the mid abdomen are multiple dilated loops of small bowel. the dilated loops are approximately until the distal jejunum, after which there is a transition zone, with no definite site localized, but after which, small bowel loops and the colon are collapsed. the findings are highly suggestive of a mechanical small bowel obstruction. fluid is present in the left paracholic gutter. no diverticuli are seen. a metallic inferior vena cava filter is present in the infrarenal ivc. ct of the pelvis with iv contrast: distal ureters and bladder are unremarkable. a small amount of fluid or thickening is present in the sigmoid mesocolon. no significant amount of free fluid is present in the pelvis. no pathologically enlarged inguinal or pelvic lymph nodes are seen. no inguinal hernias are present. (over) [**2198-4-7**] 10:16 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 85117**] ct 150cc nonionic contrast; ct reconstruction reason: location/etiology of bowel obstruction field of view: 50 contrast: optiray amt: 150 ______________________________________________________________________________ final report (revised) (cont) no suspicious lytic or sclerotic osseous lesions are identified. impression: 1. evidence of mechanical small bowel obstruction. 2. innumerable hepatic and bilateral renal cysts, with multiple possible pancreatic cysts. findings consistent with adult polycystic disease, but comparison with prior studies are reccommended to exclude a cystic pancreatic neoplasm. these results were discussed with the surgical house staff at the time of interpretation.",0
465,"[**2134-3-1**] 5:02 pm cta chest w&w/o c &recons; cta abd w&w/o c & recons clip # [**clip number (radiology) 28822**] cta pelvis w&w/o c & recons; ct 150cc nonionic contrast reason: eval for aortic dissection contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 3**] medical condition: 84 year old man with sharp back and chest pain, tingling in fingers bil, and new rle weakness. reason for this examination: eval for aortic dissection no contraindications for iv contrast ______________________________________________________________________________ wet read: eez mon [**2134-3-1**] 5:30 pm no dissection ______________________________________________________________________________ final report indications: sharp back and chest pain tingling in fingers, right lower extremity weakness, known myelodysplastic syndrome, evaluate right aortic dissection. technique: axial images of the chest, abdomen and pelvis were acquired helically from the lung apices to the inguinal canal. 150 cc of optiray contrast. there were no adverse reactions to contrast administration. findings ct of the chest with iv contrast: the thoracic aorta is of normal course and caliber. extensive mural calcifications are present. there is no surrounding hematoma, extravasation, or dissection. numerous mediastinal lymph nodes are present. two are at the upper limits of normal in size. no pathologically enlarged hilar lymph nodes are seen. there is calcification in the lad. no pleural or pericardial effusions are present. no large central pulmonary emboli are present. diffuse dependent changes are seen in the lungs. a small right-sided pleural effusion is present with associated basilar atelectasis. bronchi are patent to the subsegmental levels. ct of the abdomen with iv contrast: the abdominal aorta is normal in course and caliber. all major arterial branches, including the celiac, sma, [**female first name (un) **], and renal arteries, are patent. extensive mural calcifications are demonstrated. no peri-aortic hematoma, or evidence of acute injury is present. there is no active extravasion or dissection. no focal liver lesions are identified. the spleen is enlarged, measuring 15 cm, consistent with the patient's known myelodysplastic disease. numerous calcified gallstones are present within the gallbladder. there is no evidence of acute cholecystitis. pancreas, kidneys, stomach, and intra-abdominal loops of small and large bowel are unremarkable. there is no ascites. numerous scattered mesenteric retroperitoneal lymph nodes are seen, which do not meet size criteria for pathological enlargement. there is no ascites. ct of the pelvis with iv contrast: again there are extensive calcifications of the iliac vessels. the visualized portions of the sigmoid colon and rectum are normal. the bladder is unremarkable. distal ureters are not visualized. no (over) [**2134-3-1**] 5:02 pm cta chest w&w/o c &recons; cta abd w&w/o c & recons clip # [**clip number (radiology) 28822**] cta pelvis w&w/o c & recons; ct 150cc nonionic contrast reason: eval for aortic dissection contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) free fluid is seen throughout the visualized portions of the pelvis. diffuse degenerative changes are seen throughout the spine. multiple lucencies are demonstrated in the left femoral head anteriorly, which may be subchondral cysts. impression: 1. no evidence of aortic dissection, injury, or hematoma. 2. numerous calcified gallstones without evidence of acute cholecystitis.",0
466,"[**2145-5-3**] 6:20 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 84969**] ct 150cc nonionic contrast; ct reconstruction reason: please evaluate for evidence of ischemic colitis or other pa field of view: 38 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 2**] medical condition: 71 year old man with chronic bloody diarrhea, abd. pain reason for this examination: please evaluate for evidence of ischemic colitis or other pathologic process no contraindications for iv contrast ______________________________________________________________________________ final report (revised) indication: chronic bloody diarrhea and abdominal pain, evaluate for ischemic colitis. no prior ct scans are available for comparison. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases to the pubic symphysis with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: ct of the abdomen with iv contrast: dependent changes are seen within the lung bases. no pleural effusions are present. numerous tiny foci of decreased attenuation are present throughout the liver parenchyma. these are all too small to characterize by ct. the spleen, adrenal glands, gallbladder, stomach, and intraabdominal loops of small bowel are unremarkable. there is slight cortical atrophy and atrophy of both kidneys, along with numerous renal cysts. there is no evidence of renal obstruction. there is no ascites. no pathologically enlarged mesenteric or retroperitoneal nodes are seen. the pancreas is atrophic, but is otherwise unremarkable. there are extensive calcifications of the abdominal aorta. the origins of the celica, smv, imv, and renal arteries are patent. ct of the pelvis with iv contrast: numerous sigmoid diverticula are present. there is also rather prominent thickening of the proximal descending and transverse colon up to the level of approximately the hepatic flexure. the ascending colon wall is not thickened. thickening in the descending and transverse colon is in regions where no diverticula are present. this is a non-specific finding, and may represent an ischemic, infectious, or inflammatory process. air is present within the urinary bladder, although no foley catheter is seen. this should be correlated with prior urinary catheterization history. there is also thickening in the left lateral bladder wall adjacent to the sigmoid diverticuli. this could represent enterocystic fistula if there is no prior history of bladder catheterization or instrumentatino. there is no free fluid in the pelvis or pathologically enlarged inguinal or pelvic nodes. degenerative changes are seen throughout the spine. no suspicious lytic or sclerotic lesions are identified. (over) [**2145-5-3**] 6:20 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 84969**] ct 150cc nonionic contrast; ct reconstruction reason: please evaluate for evidence of ischemic colitis or other pa field of view: 38 contrast: optiray amt: 150 ______________________________________________________________________________ final report (revised) (cont) impression: 1) thickening of transverse and descending colon- uncomplicated. this is a non- specific finding, and may represent infection, ischemia or inflammatory changes. 2) numerous sigmoid diverticula without evidence of acute diverticulitis. 3) air in bladder. correlate clinically with prior instrumentation/catheterization in light of the adjacent sigmoid diverticulosis.",0
467,"[**2184-3-5**] 12:06 am ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 83529**] ct 150cc nonionic contrast reason: s/p mva - ? internal injury field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 30 year old man with reason for this examination: mva no contraindications for iv contrast ______________________________________________________________________________ wet read: eez fri [**2184-3-5**] 1:20 am no hepatic/splenic/renal laceration. no free fluid or air. ______________________________________________________________________________ final report indication: status post mva, ? internal injury. no prior ct scans are available for comparison. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases to the pubic symphysis with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. abdominal ct with iv contrast, findings: increased opacity is present within both lung bases which represent contusions. no pleural or paracardial effusions are present. no hepatic or splenic lacerations are seen. the kidneys enhance symmetrically without evidence of obstruction or laceration. the intraabdominal loops of small bowel are unremarkable without evidence of mesenteric fluid. there is no free intraperitoneal air or free fluid in the abdomen. the pancreas and duodenum are unremarkable. no pathologically enlarged mesenteric or retroperitoneal lymph nodes are seen. the infraaorta is rather heavily calcified with mural plaquing, which is an unusual finding given the patient's age. the aorta is normal in caliber without evidence of acute injury. pelvic ct with iv contrast, findings: the distal ureters, bladder, sigmoid colon, rectum, and prostate are unremarkable. there is no free fluid in the pelvis. no pathologically enlarged pelvic or inguinal lymph nodes are seen. lumbar and distal thoracic vertebral bodies are unremarkable. no rib fractures are seen. the visualized portions of the femurs are unremarkable. impression: no evidence of acute intraabdominal injury. calcified distal aorta. these results were discussed with the trauma team at the time of interpretation. (over) [**2184-3-5**] 12:06 am ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 83529**] ct 150cc nonionic contrast reason: s/p mva - ? internal injury field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont)",0
468,"[**2182-5-8**] 12:25 pm cta chest w&w/o c &recons; ct 100cc non ionic contrast clip # [**clip number (radiology) 54139**] reason: severe hypoxia on excertion; r/o pe. contrast: optiray amt: 100 ______________________________________________________________________________ final report indications: severe dyspnea on exertion evaluate for pulmonary embolism. comparisons: an hrct of the chest was performed earlier the same day. no prior chest ct scans are available for comparison. technique: axial images of the chest were acquired helically from the lung apices to the lung bases with 100 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: the pulmonary vasculature is well opacified. within the left basal segment there are two tiny foci of decreased attenuation, which are thought to represent flow artifact, and not emboli. a left bulla is present additional areas of ground glass, bronchiectasis, and thickened intralobular septa are present within both lung bases in the left midlung zone. for additional details, please consult the hrct report. soft tissue density is present behind the right main pulmonary artery. numerous scattered mediastinal lymph nodes are present which are at the upper limits of normal in size. no pathologically enlarged axillary nodes are present. no suspicious lytic or sclerotic osseos lesions are identified. impression: no evidence of pulmonary embolism. for additional details on the lung parenchyma, please consult the hrct report from earlier the same day.",0
469,"[**2169-4-23**] 11:22 am ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 65425**] ct 150cc nonionic contrast; ct reconstruction reason: please assess for transition point or area of mechanical obs field of view: 40 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 3**] medical condition: 74 year old man with recurrent bowel obstructions. reason for this examination: please assess for transition point or area of mechanical obstruction. please do sagittal reconstructions. no contraindications for iv contrast ______________________________________________________________________________ final report indication: recurrent small bowel obstruction, evaluate for obstruction. comparison is made to the abdominal ct from [**2169-2-21**]. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases through the pubic symphysis with 150 cc of optiray contrast. nonionic contrast was used due to patient request. there were no adverse reactions to contrast administration. findings: ct of the abdomen with iv contrast: small bilateral pleural effusions and bibasilar atelectasis is present, right greater than left. no focal liver lesions are identified. the spleen, gallbladder, pancreas, adrenal glands, and stomach are unremarkable. the kidneys enhance symmetrically without evidence of obstruction. multiple simple cysts are present bilaterally. there is marked dilation of virtually all small bowel loops. again identified is a loop ileostomy in the right anterior lower abdominal wall. the efferent loop of this ostomy is collapsed, and is well visualized to the terminal ileum, and proximal colon, which is also collapsed. the afferent limb is not as well visualized, but there is a large loop of small bowel in this region, which is the most dilated loop. the findings most likely represent an adhesion related mechanical small bowel obstruction of the anterior abdominal wall adjacent to the ileostomy site. there is mild stranding surrounding the small bowel, with a small amount of fluid in between small bowel loops in the pelvis. no pathologically enlarged mesenteric or retroperitoneal lymph nodes are seen. ct of the pelvis with iv contrast: the entire colon is collapsed. again seen are brachytherapy seeds within the prostate. the distal ureters and bladder are unremarkable. no inguinal hernia. no pathologically enlarged pelvic or inguinal lymph nodes. impression: small bowel obstruction with transition point at the anterior abdominal wall in the area of the loop ileostomy. the efferent ileostomy limb and entire colon are collapsed. small amount of fluid between multiple small bowel loops in the pelvis. (over) [**2169-4-23**] 11:22 am ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 65425**] ct 150cc nonionic contrast; ct reconstruction reason: please assess for transition point or area of mechanical obs field of view: 40 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont)",0
470,"[**2195-6-7**] 3:20 pm ct chest w/contrast; ct abdomen w/contrast clip # [**clip number (radiology) 7620**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: 75 f s/p cabg/avr [**2195-2-5**] with prolonged course, now readmi field of view: 46 contrast: optiray amt: 150cc ______________________________________________________________________________ [**hospital 3**] medical condition: 75 year old woman with reason for this examination: 75 f s/p cabg/avr [**2195-2-5**] with prolonged course, now readmitted with sepsis. has large sternal wound. patient gets dialysis-may receive contrast. no contraindications for iv contrast ______________________________________________________________________________ final report indication: large sternal wound, prolonged hospital course, now with sepsis. rule out source of infection. comparison is made to the chest ct and abdominal ct from [**2195-5-26**]. technique: axial images of the torso were acquired helically from lung apices through the pubic symphysis with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: ct of the chest with iv contrast: again seen is a moderately large left-sided pleural effusion and a smaller right effusion. the left effusion is associated with compressive atelectasis at the left lower lobe, which is nearly completely consolidated. additional smaller patchy areas of consolidation are present in both lungs which are unchanged since the prior study. a superimposed infectious process could be present in either lower lobe. again seen are numerous prominent mediastinal lymph nodes which are unchanged in size or appearance. no pathologically enlarged hilar or axillary nodes are seen. the sternal wound is again visualized. there are stable small fluid collections posterior to the sternum inferiorly anterior to the heart base which are stable in appearance. ct of the abdomen with iv contrast: the study is limited by beam hardening artifact from the patient's arms, which she was not able to lift over her head. allowing for these limitations, no focal liver lesions are identified. the spleen, pancreas, adrenal glands, kidneys, stomach, gallbladder, and intra-abdominal loops of small and large bowel are unremarkable. a small amount of fluid is present posterior to the liver edge and the spleen edge, in the most dependent areas of the lateral peritoneal recesses. the abdominal aorta is densely calcified. numerous surgical clips are demonstrated in the retroperitoneum. there is no free fluid in the abdomen, and no evidence of abscess. no free intraperitoneal air. ct of the pelvis with iv contrast: again demonstrated is a large anterior abdominal wall defect, which contains nonincarcerated nonobstructed small bowel. there is no free fluid in the pelvis, and no evidence of pelvic abscess. the bladder is unremarkable. no pelvic or inguinal lymphadenopathy. (over) [**2195-6-7**] 3:20 pm ct chest w/contrast; ct abdomen w/contrast clip # [**clip number (radiology) 7620**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: 75 f s/p cabg/avr [**2195-2-5**] with prolonged course, now readmi field of view: 46 contrast: optiray amt: 150cc ______________________________________________________________________________ final report (cont) again seen are extensive degenerative changes within the spine. no suspicious lytic or sclerotic osseous lesions are identified. impression: 1. left lower lobe collapse, stable bilateral pleural effusions (left greater than right), and patchy areas of consolidation within both lungs, stable in appearance, but a superimposed infectious process cannot be excluded. 2. stable sternal wound healing by secondary intent, with stable retrosternal fluid collection behind xyphoid process. 3. no intra-abdominal abscess or intrapelvic abscess. 4. large anterior abdominal wall defect without evidence of strangulation or incarceration. these results were discussed with the clinical house staff at the time of interpretation.",0
471,"[**2160-4-20**] 2:27 pm ct abd w&w/o c; ct pelvis w/contrast clip # [**clip number (radiology) 80058**] ct 150cc nonionic contrast reason: eval for recurrence of hepatic abscess, rt pleural effusion, abdominal pain field of view: 36 contrast: optiray amt: 150cc ______________________________________________________________________________ [**hospital 4**] medical condition: 57 year old woman with h/o hepatic abscess, r effusion, s/p drainage of both, roux-en-y, hepaticojejunostomy. reason for this examination: eval for recurrence of hepatic abscess, r pleural effusion for loculation no contraindications for iv contrast ______________________________________________________________________________ wet read: eez sun [**2160-4-20**] 3:15 pm residual fluid collection with enhancing rim in hepatic dome, and extending around area of omental packing in liver. ______________________________________________________________________________ final report *abnormal! indications: history of hepatic abscess, right effusion status post drainage. comparison is made to the abdominal ct from [**2160-1-14**]. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases through the pubic symphysis before and after administration of 150 cc of optiray contrast, in multiple phases. there were no adverse reactions to contrast administration. findings: ct of the abdomen with iv contrast: a moderately large right-sided pleural effusion is present. the effusion is larger than on the prior study. no pericardial effusion is seen. atelectasis is seen within the right lung base. changes are present from omental packing of a cyst within the right lobe of the liver. again seen is a large fluid collection surrounding the omental fat packing, which is essentially unchanged in size compared to the [**1-14**] study, and likely represents the patient's known hematoma. the area is slightly different in appearance on today's study, demonstrating a thicker enhancing wall, and an internal septation. the ptc tubes and percutaneous draining catheters have been removed. there has been interval progression of intrahepatic biliary ductal dilatation, right greater than left. there is free fluid in the portal hepatis. again seen are numerous focal areas of decreased attenuation throughout the liver parenchyma which are unchanged in size or appearance. the spleen, pancreas, adrenal glands, kidneys, stomach, and intraabdominal loops of small and large bowel are stable in appearance. there is a small amount of ascitic fluid anterior to the liver. scattered non-pathologically-enlarged mesenteric and retroperitoneal nodes are again seen. ct of the pelvis with iv contrast: distal ureters, bladder, sigmoid colon and rectum are unremarkable. there is no free fluid in the pelvis or pathologically enlarged inguinal or pelvic lymph nodes. no suspicious lytic or sclerotic osseous lesion are identified. (over) [**2160-4-20**] 2:27 pm ct abd w&w/o c; ct pelvis w/contrast clip # [**clip number (radiology) 80058**] ct 150cc nonionic contrast reason: eval for recurrence of hepatic abscess, rt pleural effusion, abdominal pain field of view: 36 contrast: optiray amt: 150cc ______________________________________________________________________________ final report *abnormal! (cont) impression: 1) increasing right-sided pleural effusion. 2) fluid collection in liver stable in size, but now demonstrates an internal septation and increased wall thickening. findings are consistent with an organizing hematoma. 3) interval removal of biliary stents with increasing intrahepatic biliary ductal dilatation. these results were discussed with the emergency department and surgical house staff at the time of interpretation.",0
472,"[**2110-7-19**] 6:33 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 42854**] ct reconstruction; ct 150cc nonionic contrast reason: hx of bladder ca s/p neobladder, with persistent rectal pain field of view: 50 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 2**] medical condition: 70 year old man with reason for this examination: hx of bladder ca s/p neobladder, with persistent rectal pain, diarrhea and lower abd pain eval for fluid collection tenderness in the rectum to dre and anoscopy shows irritated rectum no contraindications for iv contrast ______________________________________________________________________________ wet read: eez sat [**2110-7-19**] 9:12 pm very mild rectal wall thickening. ______________________________________________________________________________ final report [**2110-7-19**] indication: history of bladder cancer, status post neobladder, persistent rectal pain, endoscopy shows inflamed mucosa. comparison is made to the abdominal ct from [**2110-6-4**]. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases through the pubic symphysis with 150 cc of optiray contrast. nonionic contrast was used secondary to the patient's debility. there were no adverse reactions to contrast administration. coronal reformations were made. findings: ct of the abdomen with iv contrast: a single calcified granuloma is present in the right lung base. coronary arterial calcifications are present. no pleural or pericardial effusions are seen. no focal liver lesions are identified. the gallbladder, spleen, pancreas, stomach, and intra-abdominal loops of small and large bowel are unremarkable. there is no ascites. again demonstrated is aneurysmal dilatation of the infrarenal aorta which extends into the left iliac artery. maximal dimensions of the aneurysm on today's study are 3.6 x 4.3 cm for the infrarenal aorta, and 2.4 cm for the left iliac. the ostia of the celiac, sma, [**female first name (un) **], and renal arteries are calcified, but patent. overall appearance is stable. the kidneys enhance symmetrically with numerous simple cysts bilaterally. there is stable hydronephrosis of the right kidney with hydroureter. the previously seen nephrostomy tube has been removed. there are surgical staples adjacent to the insertion of the right ureter into the neobladder. ct of the pelvis with iv contrast: the appearance of the neobladder is unchanged. there is very mild wall thickening of the rectum with surrounding stranding. this correlates with the inflammatory changes seen on endoscopy. the sigmoid colon is unremarkable. there is no free fluid in the pelvis or (over) [**2110-7-19**] 6:33 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 42854**] ct reconstruction; ct 150cc nonionic contrast reason: hx of bladder ca s/p neobladder, with persistent rectal pain field of view: 50 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) pathologically enlarged inguinal or pelvic lymph nodes. extensive degenerative changes are seen in the spine. no suspicious lytic or sclerotic lesions are identified. ct reconstructions: coronal reformations demonstrate stable right hydronephrosis and a mildly thickened rectal wall. impression: 1. very mild rectal wall thickening corresponds to inflammatory changes seen at endoscopy. the findings may represent proctitis. 2. stable hydroureter and hydronephrosis in the right kidney. nephrostomy tube has been removed. the appearance of the neobladder is unchanged. these results were discussed with the emergency department house staff at the time of interpretation.",0
473,"[**2196-7-4**] 6:05 pm cta chest w&w/o c &recons; ct 100cc non ionic contrast clip # [**clip number (radiology) 59459**] reason: cta to rule out pe admitting diagnosis: liver failure contrast: optiray amt: 100 ______________________________________________________________________________ [**hospital 2**] medical condition: 60 year old woman with low pa pressures for her reason for this examination: cta to rule out pe no contraindications for iv contrast ______________________________________________________________________________ final report indication: low pulmonary arterial pressures, evaluate for pulmonary embolism. no prior chest ct scans are available for comparison. technique: axial images of the chest were aquired helically with 100 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: ct chest with iv contrast: due to the patient's iv access, which was only peripheral, contrast had to be injected through a central line, resulting in suboptimal opacification of the pulmonary arterial anatomy. no large central pulmonary emboli are identified, and there are no emboli in the first order branches. evaluation of second and more distal branches is limited. there are small bilateral pleural effusions, right greater than left. there is cardiomegaly. no pericardial effusions are present. there are areas of atelectasis in both lung bases, with more patchy areas of ground glass opacity scattered through the left lung. a small hiatal hernia is present. no pathologically enlarged axillary, mediastinal, or hilar nodes are seen, although small nodes are present in the pretracheal and ap window. there is no pneumothorax. note is made of abnormal parenchymal enhancement in both the liver and spleen, which may be related to bolus injection timing. no suspicious lytic or sclerotic osseous lesions are identified. impression: 1) limited study. only main pulmonary artery and first order branches visualized. there is no embolus in these branches. 2) bilateral small pleural effusions with associated bibasilar atelectasis. 3) patchy areas of ground glass opacity in the left lung, with associated cardiomegaly. these results were discussed with the surgical house staff at the time of interpretation.",0
474,"[**2177-7-21**] 4:56 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 93352**] ct reconstruction; ct 150cc nonionic contrast reason: s/p whipple, air fluid level in porta hepatis ?abscess admitting diagnosis: coronary artery disease\cath contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 85 year old man with reason for this examination: r/o appy no contraindications for iv contrast ______________________________________________________________________________ final report indications: abdominal pain. evaluate for appendicitis or mesenteric ischemia. no prior ct scans are available for comparison. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases through the pubic symphysis before and after administration of 150 cc of optiray contrast. non-ionic contrast was used per patient request. there were no adverse reactions to contrast administration. findings: ct of the abdomen with iv contrast: there are bibasilar consolidations with small pleural effusions. a mediastinal drain and left-sided chest tube are present. there is a small loculated pneumothorax on the left. no focal hepatic lesions are identified. the gallbladder is distended without evidence of cholecystitis. the spleen demonstrates areas of abnormal enhancement, which may represent infarcts. the left kidney also demonstrates segmental areas of decreased perfusion in both the upper and lower pole which may represent infarcts. numerous bilateral renal cysts are present. no right-sided renal perfusion abnormalities are noted. the pancreas and stomach are unremarkable. the intraabdominal loops of small bowel are opacified proximally, and at the upper limit of normal in size. no contrast has passed into the distal small bowel loops. there is a small amount of free fluid in the abdomen anterior to the liver. no pathologically enlarged mesenteric or retroperitoneal nodes are seen. the abdominal aorta is diffusely calcified and demonstrates extensive mural plaquing. the infrarenal abdominal aorta also demonstrates minimal aneurysmal dilatation with a maximum diameter of 3.1 cm. the dilation extends into both common iliac arteries, where the caliber returns to normal. within the region of the hepatic flexure is a focal segment of colonic wall thickening. there is minimal surrounding stranding. this loop of colon is not completely distended, however, limiting evaluation. numerous diverticula are seen in this area. ct of the pelvis with iv contrast: there is no free fluid in the pelvis. a foley catheter is present within the bladder. extensive sigmoid and (over) [**2177-7-21**] 4:56 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 93352**] ct reconstruction; ct 150cc nonionic contrast reason: s/p whipple, air fluid level in porta hepatis ?abscess admitting diagnosis: coronary artery disease\cath contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) descending colonic diverticula are present without evidence of acute diverticulitis. the appendix is well visualized, and is unremarkable. the prostate is normal in size. no pathologically enlarged inguinal or pelvic nodes are seen. osseous structures: multilevel degenerative changes are seen throughout the spine. no suspicious lytic or sclerotic osseous lesions are identified. ct reconstructions: coronal reformations show multiple enhancement defects in the left kidney and the spleen, which are suggestive of infarcts. the abnormal area of colonic wall thickening is also present. impression: 1) multiple enhancement defects in the spleen and in the left kidney. these may represent infarcts. 2) segmental area of hepatic flexure of colon, which although not fully distended, which limits evaluation, demonstrates wall thickening. this is a nonspecific finding and may indicate right sided diverticulitis or ischemia. 3) mild aneurysmal dilatation of the infrarenal aorta. 4) prominent loops of small bowel, containing oral contrast. no oral contrast has entered the terminal ileum or colon. follow-up with clinical exam findings and future abdominal radiographs. 5) left lower lobe consolidation, with loculated pneumothorax and chest tube placement. small right pleural effusion with associated atelectasis.",0
475,"[**2114-8-6**] 5:05 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 90351**] ct 100cc non ionic contrast reason: hi-res chest ct with air-fluid level in porta hepatis, pt wi admitting diagnosis: hypoventilation contrast: optiray amt: 100 ______________________________________________________________________________ [**hospital 4**] medical condition: 62 year old woman with fever, elevated wbc with bandemia, h/o gastrinoma, h/o cholangitis s/p whipple surgery reason for this examination: hi-res chest ct with air-fluid level in porta hepatis, pt with new fever and gram-neg rods in blood. concerned for abscess. please evaluate for possible drainage. no contraindications for iv contrast ______________________________________________________________________________ final report indications: fever, elevated white count with bandemia, evaluate for intraabdominal abscess. reference is made to an abdominal ultrasound from [**2114-8-5**]. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases through the pubic symphysis with 100 cc of optiray contrast. non-ionic contrast was used secondary to the patient's cardiac history. there were no adverse reactions to contrast administration. findings: ct of the abdomen with iv contrast: a central venous line is see at the junction of the svc and the right atrium. bilateral pleural effusions are present, right greater than left. the right effusion is small in size. there are bibasilar areas of atelectasis. no pericardial effusions are seen. no focal liver lesions are identified. numerous clips are present in the right upper quadrant and in the upper abdomen from prior cholecystectomy and whipple procedure. no fluid collections are seen in the region of the porta hepatis. a small amount of fluid is seen around the spleen which demonstrates low [**doctor last name **] consistent with ascitic fluid. the pancreas and left kidney are unremarkable. the right kidney is mildly ptotic. there is a slight fullness in the left adrenal gland which is not fully evaluated on this study. the right adrenal gland is normal. evaluation of the bowel is limited without oral contrast. note is made of a midline umbilical hernia which contains a loop of bowel. the bowel loops are normal in caliber, and although there is some gaseous distention low in the left pelvis, there is no evidence of proximal small bowel obstruction. there is a focal area located immediately underneath the stomach which appears slightly irregular, and it is not clear whether this is the bottom of the stomach, or whether there are superimposed small bowel loops in this region. ct of the pelvis with iv contrast: a foley catheter is present within the bladder. a large amount of stool is seen in the cecum. the uterus is unremarkable. (over) [**2114-8-6**] 5:05 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 90351**] ct 100cc non ionic contrast reason: hi-res chest ct with air-fluid level in porta hepatis, pt wi admitting diagnosis: hypoventilation contrast: optiray amt: 100 ______________________________________________________________________________ final report (cont) diffuse degenerative changes are seen throughout the spine. no suspicious lytic or sclerotic osseous lesions are identified. impression: 1) no intraabdominal fluid collection suggestive of abscess formation. evaluation of the abdomen is limited without oral contrast. 2) small umbilical hernia. 3) bilateral effusions right greater than left.",0
476,"[**2167-7-14**] 6:35 pm cta chest w&w/o c &recons; ct abdomen w/contrast clip # [**clip number (radiology) 56046**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: s/p mvc contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 2**] medical condition: 81 year old man with 1st rib fracture, s/p mvc reason for this examination: r/o aortic injury no contraindications for iv contrast ______________________________________________________________________________ wet read: eez tue [**2167-7-14**] 7:08 pm multiple bilateral rib fractures. no dissection/hematoma. no traumatic abdominal injury. ______________________________________________________________________________ final report *abnormal! indication: 1st rib fracture s/p mvc evaluate for aortic injury. no prior studies are available for comparison. technique: axial images of the chest abdomen and pelvis were acquired helically with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: ct of the chest with iv contrast: the thoracic aorta is normal in course and caliber, but is calcified with mural plaquing. no extravasation of periaortic hematoma is noted. there is no pneumothorax. note is made of multiple bilateral rib fractures in the anterolateral aspect of both thoracic walls. dependent changes are seen within the lungs. mild emphysematous changes are present, along with calcified pleural plaques in both lung bases. no pathologically enlarged axillary, mediastinal, or hilar lymph nodes are seen. no pleural or pericardial effusions are present. ct of the abdomen with iv contrast: a small hiatal hernia is present. no liver lesions or lacerations are present. the spleen is normal. the adrenal glands, duodendum, small bowel, and stomach are unremarkable. the abdominal aorta is heavily calcified with mural plaquing but is normal in caliber. numerous simple renal cysts are present bilaterally. the largest is in the right upper pole which measures 59 mm in greatest dimension. there is no free fluid in the abdomen or pathologic enlarged mesenteric or retroperitoneal lymph nodes. ct of the pelvis with iv contrast: distal ureters, bladder, sigmoid colon, and retum are normal. there is no free fluid in the pelvis. no pathologically enlarged inguinal or pelvic nodes are seen. osseous structures: multiple bilateral rib fractures are present. degenerative changes are seen throughout the spine. no pelvic fractures are noted. note is made of a bone island in the left femoral head, in a cystic area within the right humeral head. (over) [**2167-7-14**] 6:35 pm cta chest w&w/o c &recons; ct abdomen w/contrast clip # [**clip number (radiology) 56046**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: s/p mvc contrast: optiray amt: 150 ______________________________________________________________________________ final report *abnormal! (cont) ct reconstructions: coronal and sagittal reformations demonstrate no evidence of thoracic aortic injury. impression: 1) multiple bilateral rib fractures. no pneumothorax. 2) no aortic injury. 3) no acute traumatic injury in the abdomen. 4) multiple simple renal cysts bilaterally. 5) hiatal hernia.",0
477,"[**2162-5-17**] 4:31 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 102024**] ct 150cc nonionic contrast; ct reconstruction -59 distinct procedural service reason: abdominal pain, fevers, s/p colectomy with hartmans pouch field of view: 36 contrast: optiray amt: 100 ______________________________________________________________________________ [**hospital 2**] medical condition: 45 year old woman with crohns reason for this examination: abdominal pain fevers s/p colectomy with hartmans pouch no contraindications for iv contrast ______________________________________________________________________________ wet read: eez mon [**2162-5-17**] 5:32 pm marked, diffuse small bowel wall thickening. possible pneumatosis. gallstone in cbd. ______________________________________________________________________________ final report *abnormal! indication: left lower quadrant pain, history of crohn's disease, status post colectomy with end ileostomy. comparison is made to the abdominal ct scan from [**2162-4-19**]. technique: axial images of the abdomen were acquired helically from the lung bases to the pubic symphysis with 150 cc optiray contrast. there were no adverse reactions to contrast administration. coronal reformations were made. findings: ct of the abdomen with iv contrast: minor linear atelectatic changes are present in the lung bases. no focal liver lesions are identified. the spleen, adrenal glands, pancreas, stomach and kidneys are unremarkable. the gallbladder is not distended but one stone is present within the cystic duct, and another stone is present within the common bile duct. note is made of massive diffuse small bowel wall thickening with surrounding fat stranding. multiple air pockets are seen along the posterior wall of numerous loops of small bowel. the findings are consistent with pneumatosis. additionally, there are multiple loculated fluid collections, which are adjacent to multiple small bowel loops. some of these fluid collection also contain internal air. oral contrast passes freely from the stomach into the patient's ostomy, without evidence of obstruction. ct of pelvis with iv contrast: distal ureters, bladder and female reproductive structures are unremarkable. the sigmoid remnant is visualized. there is no free fluid in the pelvis or pathologically enlarged inguinal or pelvic lymph nodes. osseous structures are unremarkable. ct reconstructions: coronal reformations demonstrate massive small bowel wall (over) [**2162-5-17**] 4:31 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 102024**] ct 150cc nonionic contrast; ct reconstruction -59 distinct procedural service reason: abdominal pain, fevers, s/p colectomy with hartmans pouch field of view: 36 contrast: optiray amt: 100 ______________________________________________________________________________ final report *abnormal! (cont) thickening with creeping fat and loculated fluid collections adjacent to small bowel loops, which contain air. impression: 1. marked small bowel wall thickening of entire visualized small bowel, with likely pneumatosis and adjacent loculated fluid pockets with internal air. bowel wall thickening is suggestive of crohn's disease. no evidence of obstruction. 2. stones in cystic duct and in common bile duct. gallbladder nondistended. these results were discussed with the surgical house staff at the time of interpretation.",0
478,[**2162-5-17**] 4:31 pm cta chest w&w/o c &recons clip # [**clip number (radiology) 22237**] reason: left chest pain r/o pe field of view: 34 contrast: optiray amt: 100 ______________________________________________________________________________ [**hospital 3**] medical condition: 45 year old woman with crohns reason for this examination: abdominal pain fevers s/p colectomy with hartmans pouch also with pleuritic left chest pain and is s/p surgery r/o pe no contraindications for iv contrast ______________________________________________________________________________ wet read: eez mon [**2162-5-17**] 4:49 pm no pe ______________________________________________________________________________ final report indication: pain fevers and tachycardia s/p surgery evaluate for pulmonary embolus. no prior chest ct scans available for comparison. technique: axial images of the chest were acquired helically with 100 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: ct of the chest with iv contrast: the pulmonary vasculature is well opacified and demonstrates no intraluminal filling defects suggestive of pulmonary embolus. no pathologically enlarged mediastinal or hilar lymph nodes are seen. no pleural or pericardial effusions are present. the bronchi are patent to the subsegmental levels. the lung parenchyma is clear with the exception of minor linear atelectasis in both lung bases. osseous structures are unremarkable. impression: no evidence of pulmonary embolism.,0
479,"[**2151-5-8**] 2:37 pm ct neck w/contrast (eg:parotids); ct 100cc non ionic contrast clip # [**clip number (radiology) 87686**] reason: r/o abscess, focal etiology of l neck pain contrast: optiray amt: 100cc ______________________________________________________________________________ [**hospital 2**] medical condition: 69 year old man with new dual chamber icd placed ~10 days ago. transferred from rehab today with acute onset l neck pain. reason for this examination: r/o abscess, focal etiology of l neck pain no contraindications for iv contrast ______________________________________________________________________________ wet read: eez sat [**2151-5-8**] 3:48 pm no abscess or lyphadenopathy ______________________________________________________________________________ final report indication: recent pacemaker placement, now with acute onset left neck pain, evaluate for abscess or focal mass. no prior cervical spine ct scans are available for comparison. technique: axial images of the neck were acquired helically from the lung apices through the skull base with 100 cc of optiray contrast. nonionic contrast was used secondary to patient's cardiac history. there were no adverse reactions to contrast administration. findings: ct of the neck with iv contrast: the parotid and submandibular glands are symmetrical. there is no prevertebral soft tissue swelling. vascular structures are normal in course. there are extensive calcifications in the carotid bifurcation on the left. a metallic marker is present over the patient's area of pain. there is an external vein in this area, without surrounding stranding. there is no cervical lymphadenopathy. no fluid collections are present to suggest the presence of abscess. the patient's left anterior chest wall icd is visualized, but beam hardening artifact limits evaluation of the surrounding soft tissue. no focal masses or muscular irregularities are seen. degenerative changes are seen throughout the cervical spine. the aortic arch is calcified. impression: no abscess, cervical adenopathy, or abnormality seen in the region of patient's pain.",0
480,"[**2111-8-1**] 1:44 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 93653**] ct 150cc nonionic contrast reason: trauma field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 53 year old man with trauma reason for this examination: trauma no contraindications for iv contrast ______________________________________________________________________________ wet read: eez sat [**2111-8-1**] 3:52 pm no traumatic intra-abdominal injury. ______________________________________________________________________________ final report indication: trauma. no prior ct scans are available for comparison. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases through the pubic symphysis with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: ct of the abdomen with iv contrast: there is a tiny lucent focus of air along the right paraspinal line, which may indicate a tiny, insignificant pneumothorax. no pleural or pericardial effusions are present. minor dependent changes are seen within the lung bases. there is no free intra- abdominal air. no liver lacerations or splenic lacerations are seen. a single rounded calcified focus is present in the left medial lobe of the liver which represents a granuloma. the adrenal glands, gallbladder, stomach, and small bowel are unremarkable. the kidneys enhance symmetrically without focal mass or obstruction. the pancreas and duodenum are normal. the abdominal aorta is of normal caliber throughout its visualized length and demonstrates mild mural plaquing with calcification. there is no ascites or pathologically enlarged mesenteric or retroperitoneal lymph nodes. ct of the pelvis with iv contrast: the distal ureters are unremarkable. the bladder contains a foley catheter and air. there is stool within the appendix, which demonstrates wall enhancement. this is likely related to bolus timing. there is sigmoid diverticular disease without evidence of diverticulitis. there is no free fluid in the pelvis or pathologically enlarged inguinal or pelvic nodes. osseous structures: no fractures are seen. impression: no evidence of acute intra-abdominal injury. diverticulosis without evidence of diverticulitis. small calcified granuloma within the liver. (over) [**2111-8-1**] 1:44 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 93653**] ct 150cc nonionic contrast reason: trauma field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont)",0
481,"[**2147-9-12**] 5:51 pm ct lumbar w&w/o contrast; ct 100cc non ionic contrast clip # [**clip number (radiology) 81489**] ct reconstruction reason: please assess for abscess admitting diagnosis: wound infection r/o sepsis contrast: optiray amt: ______________________________________________________________________________ [**hospital 4**] medical condition: 60 year old man with dehiscent wound reason for this examination: please assess for abscess no contraindications for iv contrast ______________________________________________________________________________ final report indication: dehiscent wound. evaluate for abscess. technique: contiguous axial images through the lumbar spine were acquired helically from l2 through s1, before and after administration of 100 cc optiray contrast. coronal and sagittal reformations were made. there were no adverse reactions to contrast administration. findings: again identified is extensive destruction of the l5 vertebral body and the left l5 pars interarticularis. there is a drainage catheter present posterior to the posterior longitudinal muscular fascial layer, which does not come into contact with the patient's large fluid collection, which extends from the posterior paraspinal musculature, surrounding the spinal canal at l5, and entering into the l5 vertebral body. there is relative preservation of the fat planes around the thecal sac, and the dura appears intact. after contrast administration, there is no definite enhancing rim, but numerous air pockets are present in different regions of the fluid collection. with the exception of the gas bubbles, which are new, the appearance is unchanged. impression: new air bubbles in previously seen complex fluid collection surrounding the spinal canal and involving the posterior paraspinal musculature and l5 vertebral body. the new gas bubbles may be related to gas production from infecting organisms, instrumentation, or from communication with patient's known dehiscent wound. finding is nonspecific, and correlation with gram stain findings is recommended. if infected, there is likely osteomyelitis of the osseous structures. these results were discussed with dr. [**first name4 (namepattern1) 3289**] [**last name (namepattern1) 10474**] at the time of interpretation.",0
482,"[**2136-11-5**] 4:11 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 58981**] ct 150cc nonionic contrast reason: eval abd for hematoma, abscesshct drops and abd pain s/p ex admitting diagnosis: liver failure contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 68f s/p liver transplant reason for this examination: eval abd for hematoma, abscesshct drops and abd pain s/p ex lap hematoma evacuation no contraindications for iv contrast ______________________________________________________________________________ final report indication: hematocrit drop, status post liver transplant. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases to the pubic symphysis with 150 cc optiray contrast. nonionic contrast was used secondary to language barrier. there were no adverse reactions to contrast administration findings: comparison is made to the [**2136-11-1**] ct. ct of the abdomen w/iv contrast: there has been reaccumulation of a small to moderate-sized left pleural effusion. the right pleural effusion is smaller and contains a chest tube. there is extensive bibasilar atelectasis. no pericardial effusion is seen. a right upper quadrant drainage catheter is present. postsurgical changes in the anterior abdominal wall are unchanged. the previously seen large perihepatic fluid collection with fluid-fluid levels has largely resolved. there is a residual pocket anterior to the right lobe of the liver inferiorly, which contains a small amount of air, likely postsurgical. the pocket measures 2.6 x 10.1 cm. numerous additional drainage catheters are present in the abdomen. there is stable air within the intrahepatic bile ducts. there is a small to moderate amount of free fluid throughout the abdomen, seen more in the dependent portions, which may represent new fluid or redistribution from the prior perihepatic collection. the fluid attenuation values are not consistent with adcute blood products. the spleen, kidneys, pancreas, and stomach are unremarkable. there is a prominent conglomerate of dilated small bowel loops in the right lower quadrant. distal to this, the small bowel loops appear collapsed. note is made that oral contrast has passed all the way into the colon at the time of scanning. findings likely represent a partial small bowel obstruction. ct of the pelvis w/iv contrast: there is a moderate amount of free fluid. contrast is present throughout the colon. the bladder contains a foley catheter. distal ureters are unremarkable. no pathologically enlarged inguinal or pelvic nodes are seen. impression: (over) [**2136-11-5**] 4:11 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 58981**] ct 150cc nonionic contrast reason: eval abd for hematoma, abscesshct drops and abd pain s/p ex admitting diagnosis: liver failure contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) 1. vast improvement in size of perihepatic fluid collection with small amount of residual fluid anterior to right anterior lobe inferiorly, which contains small air bubbles. 2. prominent conglomerate of dilated small bowel loops in the right lower quadrant with decompressed distal small bowel loops. contrast does pass freely into the rectum, and findings likely represent a partial small bowel obstruction. 3. increased amount of free fluid within the abdomen as described above. attenuation values are not that of acute blood. no cause for hematocrit drop identified. findings were discussed with dr [**first name (stitle) 3588**] [**name (stitle) 1913**] at the time of interpretation at 17:30 on [**2136-11-5**].",0
483,"[**2138-9-15**] 1:09 pm ct chest w/contrast; ct abd w&w/o c clip # [**clip number (radiology) 35830**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: chest/abdomin/pelvis field of view: 40 contrast: optiray amt: 150 ______________________________________________________________________________ final report indication: non-hodgkin's lymphoma, for restaging. technique: contiguous axial images of the chest, abdomen and pelvis were acquired healically, before and after administration of 150 cc optiray contrast in multiple phases. nonionic contrast was used secondary to patient's debility history. there were no adverse reactions to contrast administration. findings: comparison is made to the pet-ct scan from [**2138-5-15**]. ct of the chest w/iv contrast: there are no new areas of pathologically enlarged axillary, hilar, or mediastinal lymph nodes. overall, the lungs are better inflated. there is extensive scarring along both major fissures with atelectasis in these regions. there is bronchiectasis in the right middle lobe. no frank soft tissue masses are appreciated. there is stable right pleural thickening. the aorta is extensively calcified, along with both coronary arteries. the heart and great vessels are otherwise unremarkable. there is a small right pleural effusion, which is unchanged. the bronchi are patent to the segmental levels. ct of the abdomen w/iv contrast: there are three focal areas of decreased attenuation within the liver. the largest is located within the left medial lobe, segment 4b, and was present on prior studies and is unchanged in appearance. two additional smaller foci of decresed attenuation, which are too small to characterize adequately by ct, are located within the right anterior lobe of the liver (segment 5, adjacent to the gallbladder). due to differences in technique, these were not visualized on the [**5-15**] ct portion of the pet-ct scan. they are likely unchanged. there is a focus of decreased attenuation within the posterior aspect of the spleen, which measures 2.9 x 3.7 cm and fills in on delayed imaging. this area was present on prior studies and appears slightly larger, but evaluation is limited due to differences in technique. there is a tiny focus of increased attenuation within the gallbladder, which may represent a small stone. there is no evidence of acute cholecystitis. the adrenal glands, stomach, and intraabdominal loops of small and large bowel are unremarkable. there are multiple small simple renal cysts present. the kidneys otherwise enhance symmetrically without evidence of obstruction. there is a cystic-appearing area of decreased attenuation within the uncinate process of the pancreas. this area was present on the [**5-15**] study and is unchanged in appearance. the area was partially evaluated on chest ct in [**2137-12-4**], and is also likely unchanged since then. the previously seen large aortocaval node has decreased in size. the bulky retroperitoneal pericaval lymph node conglomerate has nearly completely resolved, with mild soft tissue attenuation adjacent to the ivc and common iliac vein. (over) [**2138-9-15**] 1:09 pm ct chest w/contrast; ct abd w&w/o c clip # [**clip number (radiology) 35830**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: chest/abdomin/pelvis field of view: 40 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) ct pelvis w/iv contrast: the large left groin mass has decreased in size and now measures 22 x 39 mm. there is no free fluid in the pelvis or new pathologically enlarged inguinal or pelvic nodes. there are extensive diverticula without evidence of acute diverticulitis. distal ureters and bladder are unremarkable. no suspicious lytic or sclerotic osseous lesions are identified. there are extensive degenerative changes throughout the spine. impression: 1. marked decrease in size in aortocaval retroperiotineal lymph node conglomerate and decreased size of left groin mass. no new pathologically enlarged lymph nodes. 2. focus of decreased attenuation within the spleen may be slightly larger but difficult to interpret, as prior studies are not of the same technique. attention should be paid to the spleen findings on the fdg pet scan from the same day. 3. three foci of decreased attenuation within the liver, which are likely stable. 4. cystic area within the uncinate process of the pancreas, stable on multiple prior studies. findings may represent a focally obstructed duct or ipmt. 5. lung findings as described above.",0
484,"[**2119-11-23**] 2:40 am ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 101530**] ct 100cc non ionic contrast; ct reconstruction reason: evaluate for obstruction field of view: 36 contrast: optiray amt: 100 ______________________________________________________________________________ [**hospital 2**] medical condition: 81 year old woman s/p vesicovaginal fistula repair who p/w bilious vomiting x 3-4 days. reason for this examination: evaluate for obstruction no contraindications for iv contrast ______________________________________________________________________________ wet read: [**first name9 (namepattern2) 11053**] [**doctor first name 141**] [**2119-11-23**] 3:15 am findings consistent with mechanical small bowel obstruction, likely adhesion related, in low pelvis. new free fluid in abdomen (low density). new fluid pocket in anterior abdominal wall, possible nephrostomy leak. ______________________________________________________________________________ final report *abnormal! indications: status post vesicovaginal fistula repair, now presents with bilious vomiting. evaluate for obstruction. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases through the pubic symphysis with oral and 100 cc of optiray contrast. there were no adverse reactions to contrast administration. coronal reformats were made. comparison is made to the abdominal ct scan from [**2119-11-3**]. ct abdomen with iv contrast: there are new bilateral pleural effusions with associated bibasilar atelectasis. on the very first image, there is a rounded, nodular opacity in the right lung base. no focal liver lesions are identified. there is mild dilatation of the intrahepatic biliary ducts, which is new since the prior study. the gallbladder is distended, but there is no surrounding stranding or wall edema. the spleen, adrenal glands, and pancreas are unremarkable. both kidneys are small, and demonstrate cortical thinning, with bilateral nephrostomy tubes, which exit the anterior abdominal wall in the left lower quadrant via the new colonic conduit. the stomach is markedly distended. there is dilatation of all proximal small bowel loops. the new colostomy, now located in the right lower quadrant, is not well distended, and the distal small bowel loops low in the pelvis are collapsed compared to the more proximal loops. evaluation of low pelvic loops is limited by beam- hardening artifact from the patient's hip prosthesis. the dilatation of proximal small bowel likely due to a mechanical obstruction, although the transition point is not definitely visualized. the superior mesenteric vein is small just below the level of the portosplenic confluence. this is of unclear current clinical significance, but could predispose the patient to smv occlusion in the future. there is new moderate free fluid in the abdomen. an additional anterior abdominal wall fluid pocket is also new since the prior study. this may reflect postoperative changes, but an infection in this fluid pocket cannot be excluded. the fluid pocket (over) [**2119-11-23**] 2:40 am ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 101530**] ct 100cc non ionic contrast; ct reconstruction reason: evaluate for obstruction field of view: 36 contrast: optiray amt: 100 ______________________________________________________________________________ final report *abnormal! (cont) may also represent a leak from the nephrostomy. ct of the pelvis with iv contrast: there is an ill-defined conglomerate of bowel loops in the lower anterior abdomen. this was seen to fill with oral contrast on the prior study. there is a focal fluid pocket which demonstrates high-density material in the wall, and likely represents a suture line. evaluation is limited, however, by the extensive beam-hardening artifact in this area. also noted is an air pocket anteriorly very low in the pelvis. this could be within bowel, or extraluminal, and evaluation is limited severely by the beam-hardening artifact. extensive surgical clips are seen in the pelvis. extensive vascular calcifications are also present. there are clips in the anterior abdominal midline. osseous structures: degenerative changes are present throughout the spine. the patient is status post total left hip arthroplasty. ct reconstructions: coronal reformats show dilated small bowel loops and stomach. impression: 1) dilated small bowel loops in upper abdomen with transition point in the low pelvis, with decompressed terminal ileum and colonic loops to the level of the colostomy. findings are suspicious for a mechanical small bowel obstruction, possibly adhesion-related. 2) irrregular conglomeration of bowel loops in the low pelvis, with a focal pocket of free air in the very low pelvis. evaluate is limited by extensive beam- hardening artifact from the patient's hip prosthesis in this area. the free air may represent a post-operative air pocket. further evaluation by ct with injection of contrast into the colostomy may be helpful for further evaluation, as clinically indicated. 3) new free fluid in the abdomen. there is a new fluid pocket immediately beneath the left kidney. there is also a new pocket of free fluid in the left anterior abdominal wall, which may be post-surgical. 4) bilateral nephrostomy tubes exiting the left anterior abdominal wall via the new colonic conduit. 5) revision of colostomy, now located in right lower quadrant. 6) small smv as described above. results were discussed with dr. [**first name8 (namepattern2) **] [**last name (namepattern1) 54657**], at 3:15am on [**11-23**]. (over) [**2119-11-23**] 2:40 am ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 101530**] ct 100cc non ionic contrast; ct reconstruction reason: evaluate for obstruction field of view: 36 contrast: optiray amt: 100 ______________________________________________________________________________ final report *abnormal! (cont)",0
485,"[**2142-2-2**] 9:11 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 69409**] ct 150cc nonionic contrast reason: assess for collection, possible source of fevers admitting diagnosis: cholecystitis/sda field of view: 38 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 2**] medical condition: 58 year old man s/p kidney transplant - failed on dialysis now s/p cholecystectomy with fevers pod 7 reason for this examination: assess for collection, possible source of fevers no contraindications for iv contrast ______________________________________________________________________________ final report indication: s/p kidney transplant, and cholecystectomy with fevers on postop day 7. evaluate for fluid collection. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases through the pubic symphysis with 150 cc of optiray contrast. nonionic contrast was used secondary to the patient's renal transplant and allergy history. there were no adverse reactions to contrast administration. ct abdomen with iv contrast: minor atelectatic changes are present in the lung bases. no pleural or pericardial effusions are seen. no focal hepatic or splenic lesions are identified. there is extensive calcification of the celiac axis and mesenteric vessels, along with the abdominal aorta. both kidneys are atrophic. the pancreas, stomach, small bowel loops are all unremarkable. in the post surgical bed in the right upper quadrant is a 3.3 x 1.5 cm fluid pocket which demonstrates internal air bubbles. additionally, immediately below the skin incision line, inbetween the tranversalis and external oblique, is fluid with multiple internal air bubbles. ct pelvis with iv contrast: transplanted kidney is seen in the right lower quadrant. there is no hydronephrosis but there is an extrarenal pelvis and mild ureteral dilitation. within the large renal cyst in the transplanted kidney is a possible enhancing mural nodule which was not seen on the prior non-contrast ct. the bladder is unremarkable. a small tiny fluid pocket is seen adjacent to the lateral aspect of the distal sigmoid colon on the right. no suspicious lytic or sclerotic lesions are identified. impression: 1) two post-operative fluid collections with internal air bubbles, one in the gallbladder fossa, the other in the subcutaneous incision line. infection in these areas cannot be excluded. 2) transplanted kidney with a large cyst, which demonstrates a possible enhancing mural nodule. follow-up with ultrasound is reccommended to exclude a possible neoplastic process. fluid collection findings were discussed with dr. [**last name (stitle) 69410**], at 11 pm on (over) [**2142-2-2**] 9:11 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 69409**] ct 150cc nonionic contrast reason: assess for collection, possible source of fevers admitting diagnosis: cholecystitis/sda field of view: 38 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) [**2-2**].",0
486,"[**2180-1-30**] 3:44 am ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 2052**] reason: r/o trauma field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 2**] medical condition: 23 year old man with trauma reason for this examination: r/o trauma no contraindications for iv contrast ______________________________________________________________________________ wet read: eez sun [**2180-1-30**] 4:11 am fractures of left lumbar transverse processes l1-l4. large hematoma right groin extending along course of right femoral/iliac artery. solid abdominal organs okay. no free fluid. ______________________________________________________________________________ final report *abnormal! indication: trauma technique: axial images of the abdomen and pelvis were acquired helically from the lung bases to the pubic symphysis, with 150 cc of optiray contrast. there were no adverse reactions to contrast administration. ct abdomen with iv contrast: there is an area of consolidation in the right lung base which may represent aspiration or contusion. no pleural or pericardial effusions are seen. the liver and spleen are intact. the kidneys are intact and enhance symmetrically without surrounding fluid collection. the gallbladder, pancreas, stomach, duodenum and remainder of the small bowel are all unremarkable. there is no free intraabdominal air. there is no free fluid in the abdomen. an ng tube is present. ct pelvis with iv contrast: there is asymmetrical thickening to the right superficial femoral vein wall. there is soft tissue density surrounding the common iliac vessels, which presumably represents a hematoma from attempted right central venous line placement. maximal hematoma dimensions are 7.9 x 4.1 cm. the hematoma extends along the course of the vessels in the retroperitoneal space anterior to the psoas muscle, to the level of l5. there is no free fluid in the pelvis. air and a foley catheter is present in the bladder, along with excreted iv contrast. the distal ureters, sigmoid colon, and rectum are within normal limits. there is no free fluid in the pelvis. osseous structures: there are fractures of the left transverse processes of l1 through l4. no other fractures are identified. impression: 1) right inguinal hematoma extending along course of right liac vessels. 2) fractures of the left l1 through l4 transverse processes. 3) solid abdominal organs intact. no evidence of bowel injury. findings were discussed with the trauma team at the time of interpretation . (over) [**2180-1-30**] 3:44 am ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 2052**] reason: r/o trauma field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ final report *abnormal! (cont)",0
487,"[**2131-1-28**] 8:45 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 84820**] ct 100cc non ionic contrast; ct reconstruction reason: 45 yr old male w hx of pancreatitis with pancreatic mass (?p field of view: 36 contrast: optiray amt: 100 ______________________________________________________________________________ [**hospital 4**] medical condition: see above reason for this examination: 45 yr old male w hx of pancreatitis with pancreatic mass (?pseudocyst) leading to biliary obstruction needing stent placement. presents with one week hx of right abdominal pain. need to rule out biliary stent obstruction, pancreatitis, appendicitis. no contraindications for iv contrast ______________________________________________________________________________ wet read: eez sun [**2131-1-28**] 9:38 pm appendix normal. previously seen large presumed pseudocyst smaller. two new cystic masses, likely pseudocysts, one in body, one in tail. biliary air without ductal dilitation, unchanged from previous study. ______________________________________________________________________________ final report *abnormal! indications: history of pancreatitis, biliary obstruction with stent placement, now with one week of right abdominal pain. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases through to the pubic symphysis with 100 cc of optiray contrast. there were no adverse reactions to contrast administration. coronal reformations were made. comparison is made to the abdominal ct scan from [**2130-5-15**]. findings: ct of the abdomen with iv contrast: atelectatic changes are present in the right lung base. no pleural or pericardial effusions are present. again seen is air within the biliary system, and a stent is present in the common bile duct. the gallbladder contains several small stones and air, but is non- distended, and does not demonstrate surrounding fluid collection or inflammatory stranding. the spleen is normal. there is mild gastric wall thickening. there are calcifications throughout the pancreas indicative of chronic pancreatitis. the previously seen large pseudocyst in the head/neck of the pancreas is no longer as clearly demarcated. there are at least two new cystic structures, one in the body inferiorly, and one in the tail more superiorly. these likely represent changes from acute-on-chronic pancreatitis. there is no air within these fluid collections to indicate an abscess. there is extensive stranding around the pancreas. again seen are bilateral duplex kidneys, with dual ureters bilaterally. both lower pole moieties are atrophic and have dilated collecting systems, with areas of cortical loss secondary to chronic infection. there is hydroureter extending down the entire course of both lower pole ureters. (over) [**2131-1-28**] 8:45 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 84820**] ct 100cc non ionic contrast; ct reconstruction reason: 45 yr old male w hx of pancreatitis with pancreatic mass (?p field of view: 36 contrast: optiray amt: 100 ______________________________________________________________________________ final report *abnormal! (cont) ct of the pelvis with iv contrast: the bladder is distended. there is a small amount of fluid in the pelvis which has increased in amount since the prior study. sigmoid colon and rectum are unremarkable. no suspicious lytic or sclerotic osseous lesions are identified. ct reconstructions: coronal reconstructions demonstrate the above-discussed renal anomalies, and the two cystic structures located in the region of the pancreas. impression: 1) previously-seen pseudocyst in pancreatic head is smaller in size. at least two new cystic structures in region of pancreas, which represent changes from acute on chronic pancreatitis. 2) small amount of free fluid in the pelvis. 3) renal anomalies, as described above. 4) stable pneumobilia.",0
488,"[**2140-11-9**] 5:28 am cta chest w&w/o c &recons; cta abd w&w/o c & recons clip # [**clip number (radiology) 10809**] cta pelvis w&w/o c & recons; ct 150cc nonionic contrast reason: ro recurrent aortic dissection admitting diagnosis: thoracic dissection field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 80 year old man with cp s/p aortic dissection repair reason for this examination: ro recurrent aortic dissection no contraindications for iv contrast ______________________________________________________________________________ final report indication: chest pain after aortic dissection repair. evaluate for recurrent aortic dissection vs. pe. technique: axial images of the chest, abdomen and pelvis were acquired helically from the lung apices through the common iliac vessels, before and after administration of 150 cc of optiray contrast. nonionic contrast was used secondary to the rapid bolus injection rate required for ct angiography. there were no adverse reactions to contrast administration. mulitplanar reformations were made. findings: comparison is made to the study from [**2140-10-27**]. ct of the chest w/iv contrast: the pulmonary vasculature is well opacified and demonstrates no intraluminal filling defects suggestive of pulmonary emboli. there are changes from median sterntomy. there are changes from repair of a type 1 aortic dissection. the false lumen extemds from the proximal descending aorta throughout the chest and into the abdomen. extending superiorly from the false lumen is a slender projection of iv contrast, which extends up over the aortic arch and down the ascending aorta. this small collection of iv contrast is located posterior to the true ascending aortic lumen and courses over the arch laterally to the right of the true lumen. this extension of the false lumen is thought to represent a contained leak/pseudoaneurysm. the pseudoaneurysm/contained leak does not reach the prosthetic aortic valve or coronary orifices. it is last visualized at the level just above the left main pulmonary artery. there is a large pericardial effusion. there is a large right pleural effusion with associated compressive atelectasis of the right lower lobe. there is a smaller left pleural effusion, also associated with left basilar atelectasis. no pathologically enlarged axillary, hilar or mediastinal lymph nodes are seen. ct of the abdomen w/iv contrast: the appearance of the descending aortic dissection is unchanged compared to the prior study from [**2140-10-27**]. the true lumen perfuses the celiac artery, sma, and left renal artery. the arterial supply of the right kidney comes from the false lumen. there is no evidence of active extravasation. the dissection extends into both common (over) [**2140-11-9**] 5:28 am cta chest w&w/o c &recons; cta abd w&w/o c & recons clip # [**clip number (radiology) 10809**] cta pelvis w&w/o c & recons; ct 150cc nonionic contrast reason: ro recurrent aortic dissection admitting diagnosis: thoracic dissection field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) iliac vessels. there is no free fluid in the abdomen. the liver, gallbladder, spleen, pancreas, adrenal glands, and kidneys are all unchanged in appearance. intraabdominal loops of bowel are normal. the colon contains dense oral contrast. osseous structures are unchanged. ct reconstructions: multiplanar reformats show a slender pocket of iv contrast extending from the false lumen up over the aortic arch and down the ascending aorta. impression: 1. contained leak/pseudoaneurysm in ascending aorta and aortic arch, which is continuous with the false lumen in the descending aorta. the origins of the coronary arteries and the aortic valve are well below the extent of the pseudoaneuysm, which stops at the level of the superior aspect of the left main pulmonary artery. 2. large pericardial effusion. 3. large right pleural effusion and smaller left pleural effusion with extensive bibasilar atelectasis. 4. stable abdominal aortic dissection as described above. results were discussed with dr. [**last name (stitle) 4721**] at the time the study was performed, and after formal interpretation, at 10:00am on [**2140-11-9**].",0
489,"[**2121-2-5**] 10:00 pm cta chest w&w/o c &recons; ct abdomen w/contrast clip # [**clip number (radiology) 2727**] ct pelvis w/contrast reason: eval contusions field of view: 34 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 2**] medical condition: 84 year old woman eval pulm function reason for this examination: eval contusions no contraindications for iv contrast ______________________________________________________________________________ wet read: eez wed [**2121-2-5**] 10:41 pm no solid abdominal organ injury. asymmetric descending aortic mural plaques with ulceration. right anterior abdominal wall hematoma with evidence of active bleeding, likely originating from inferior epigastric artery. ______________________________________________________________________________ final report *abnormal! indication: trauma. evaluate for aortic injury or pulmonary contusion. technique: axial images of the chest, abdomen and pelvis were acquired helically from the neck base through the pubic symphysis with 150 cc optiray contrast. no adverse reactions to contrast administration. additional 3 minute delay images were obtained. ct chest w&w/0 contrast: there is prominence of the ascending aorta. there are extensive aortic wall calcifications and areas of mural plaqueing. there are focal pockets of contrast piercing into the mural plaques, indicative of ulceration. the mural plaques are quite thick in some areas and distributed in a patchy fashion. there is no para-aortic hematoma, frank dissection, or extravasation. there is a dense consolidation in the right middle lobe, which may indicate atelectasis or pulmonary contusion. there is cardiomegaly with areas of ground glass opacity in the pulmonary parenchyma. no pathologically enlarged axillary, hilar or mediastinal nodes are seen. there is no pneumothorax. dependent changes are seen within the lungs. there are no pleural or pericardial effusions. multiple right- sided anterior rib fractures are seen on the 5th though 10th ribs. ct abdomen w/ contrast: multiple liver cysts are seen. the liver is otherwise intact without surrounding fluid collection. numerous calcified gallstones are seen within the gallbladder which is non-distended, and demonstrates no surrounding wall stranding. the spleen is intact and enhances homogeneously. the abdominal aorta is heavily calcified but there is no evidence of dissection or active extravasation. the pancreas and duodenum are normal. the intra-abominal loops are normal in course and caliber. there is no free fluid in the abdomen. the kidneys enhance symmetrically without evidence of mass or obstruction. the adrenal glands are normal. ct pelvis w/contrast: the distal ureters are unremarkable. the bladder is collapsed and contains a foley catheter. there are extensive sigmoid diverticula without evidence of acute diverticulitis. there is no free fluid in the pelvis. (over) [**2121-2-5**] 10:00 pm cta chest w&w/o c &recons; ct abdomen w/contrast clip # [**clip number (radiology) 2727**] ct pelvis w/contrast reason: eval contusions field of view: 34 contrast: optiray amt: 150 ______________________________________________________________________________ final report *abnormal! (cont) there is standing and soft tissue density in the right anterior abdominal wall immediately anterior and medial to the anterior superior iliac spine. this likely represents a hematoma in the body wall. two serpiginous areas of high attenuation are seen which spread out on delayed phase imaging, and likely indicate acute bleeding into a hematoma. osseous structures of the pelvis and spine are within normal limits. impression: 1) asymmetric areas of mural plaqueing in the thoracic descending aorta with areas of focal ulceration. 2) right middle lobe consolidation, likely pulmonary contusion. 3) body wall hematoma anterior to right anterior superior iliac spine with evidence of active bleeding. 4) multiple hepatic cysts. no solid abdominal organ injury or free fluid in the pelvis. 5) fractures of the anterior 5th through 10th ribs. results were discussed with trauma team at time of interpretation.",0
490,"[**2142-11-20**] 9:28 pm cta chest w&w/o c &recons; ct 100cc non ionic contrast clip # [**clip number (radiology) 30508**] reason: please do cta to evaluate for lymphangitic spread, r/o pe field of view: 36 contrast: optiray amt: 100 ______________________________________________________________________________ [**hospital 2**] medical condition: 78 year old man with rcc and lung mets, esrd on hd who presents with sob, hypoxia reason for this examination: please do cta to evaluate for lymphangitic spread, r/o pe no contraindications for iv contrast ______________________________________________________________________________ wet read: eez tue [**2142-11-20**] 11:50 pm no pe. extensive mediastinal lymphadenopathy and lymphangitic spread of tumor. bilateral pleural effusions. ______________________________________________________________________________ final report *abnormal! indication: renal cell carcinoma, lung metastases and lymphangitic spread of tumor. evaluate for pulmonary embolism. technique: axial images of the chest were acquired helically from the lung bases to the lung apices, before and after administration of 100 cc of optiray contrast. nonionic contrast was used secondary to the rapid bolus injection rate required for ct pulmonary angiography. there were no adverse reactions to contrast administration. multiplanar reformations were made. comparison: [**2142-8-31**]. cta chest: the pulmonary vasculature is well opacified and demonstrates no intraluminal filling defects suggestive of pulmonary embolus. again identified is massive mediastinal lymphadenopathy, and prominent hilar adenopathy, which compresses the lingular pulmonary arterial branches. again seen are extensive confluent perihilar opacities consistent with the patient's known lymphangitic tumor spread. there has been interval progression of the opacities since the prior study. the right pleural effusion is stable in size to slightly smaller. the left effusion is significantly larger, with extensive compressive atelectasis of the left lower lobe. there is a new 17 mm pulmonary nodule in the lingula. there is a new 5 mm endobronchial lesion in the right mainstem bronchus immediately beneath the carina. a smaller nodular opacity is seen in the posterior left mainstem bronchus wall. osseous structures are unchanged, again showing diffuse degenerative changes in the spine. ct reconstructions: multiplanar reformatations show no evidence of pulmonary embolism. impression: 1) no evidence of pulmonary embolism. 2) extensive perihilar opacities, mediastinal and hilar lymphadenopathy, and bilateral pleural effusions. there is worsening lymphangitic spread of tumor and a new 17 mm lingular nodule. (over) [**2142-11-20**] 9:28 pm cta chest w&w/o c &recons; ct 100cc non ionic contrast clip # [**clip number (radiology) 30508**] reason: please do cta to evaluate for lymphangitic spread, r/o pe field of view: 36 contrast: optiray amt: 100 ______________________________________________________________________________ final report *abnormal! (cont) 3) new endobronchial lesions in the origins of both mainstem bronchi as described above.",0
491,"[**2182-2-1**] 10:40 pm cta chest w&w/o c &recons; ct 150cc nonionic contrast clip # [**clip number (radiology) 62690**] reason: h/o dvt/pe.pleuritic cp.r/o pe field of view: 40 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 2**] medical condition: 41 year old woman with h/o dvt/pe presents with low inr, pleuritic cp, lightheadedness similar to past pe sx. of note, pe diagnosed last month after abd surgery. reason for this examination: r/o pe no contraindications for iv contrast ______________________________________________________________________________ wet read: eez fri [**2182-2-1**] 11:48 pm multiple lobar emboli with one embolus in right main pulmonary artery. all emboli located in areas where embolus was present in [**2181-12-27**]. ______________________________________________________________________________ final report *abnormal! indication: history of pe on [**12/2181**], subtherapeutic on coumadin, now complaining of pleural chest pain. technique: axial images of the chest were acquired helically from the lung bases through the lung apices before/after administration of 100 cc of optiray contrast. optiray contrast was used secondary to rapid bolus injection required for pulmonary ct angiography. there were no adverse reactions to contrast administration. multiplanar reformations were made. findings: comparison is made to the study from [**2181-12-27**]. ct of the chest with iv contrast: the pulmonary vasculature is well opacified and demonstrates multiple segmental pulmonary emboli. there is also embolus in the right main pulmonary artery. compared to the prior study from [**2181-12-27**], however, all of the visualized emboli on today's study are in the same location as previously demonstrated emboli. the sheer size of the emboli on today's study is slightly smaller than on the previous study. however, the appearance of the emboli is still located centrally within the vessels, which is usually a sign of acute embolism. no pathologically enlarged, axillary, hilar or mediastinal lymph nodes are seen. minor dependent changes are seen in the lung periphery posteriorly. no focal consolidations or evidence of pulmonary infarction are present. patchy areas of nonspecific ground glass opacity are present in both lungs. there are no pleural or pericardial effusions. limited evaluation of the upper abdomen is unremarkable. no suspicious lytic or sclerotic osseous lesions are present. there is a healing right posterior rib fracture. ct reconstructions: multiplanar reformations show multiple segmental pulmonary emboli, and an embolus within the right main pulmonary artery. impression: multiple segmental pulmonary emboli, and embolus in the right main pulmonary artery. visualized emboli on today's study are all in locations where emboli were seen on the [**2181-12-27**] study. overall embolic volume is smaller. it is unclear whether these represent new acute pulmonary emboli, or incompletely (over) [**2182-2-1**] 10:40 pm cta chest w&w/o c &recons; ct 150cc nonionic contrast clip # [**clip number (radiology) 62690**] reason: h/o dvt/pe.pleuritic cp.r/o pe field of view: 40 contrast: optiray amt: 150 ______________________________________________________________________________ final report *abnormal! (cont) resolved previous emboli. no evidence of pulmonary infarction. results were discussed with dr. [**first name8 (namepattern2) 10166**] [**last name (namepattern1) 1781**], the emergency department physician, [**name10 (nameis) **] the time the study was performed.",0
492,"[**2188-2-1**] 11:09 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 96828**] ct 100cc non ionic contrast reason: patient s/p fall down 10 stairs with abd tenderness, r/o tra field of view: 36 contrast: optiray amt: 100 ______________________________________________________________________________ final addendum addendum: additional information has been obtained from careweb clinical lookup since the approval of the original report. reason for exam should also state nausea and vomitting. [**2188-2-1**] 11:09 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 96828**] ct 100cc non ionic contrast reason: patient s/p fall down 10 stairs with abd tenderness, r/o tra field of view: 36 contrast: optiray amt: 100 ______________________________________________________________________________ [**hospital 2**] medical condition: 50 year old woman with above reason for this examination: patient s/p fall down 10 stairs with abd tenderness, r/o trauma no contraindications for iv contrast ______________________________________________________________________________ wet read: eez sat [**2188-2-2**] 1:58 am liver/spleen/kidneys intact. no free air or free fluid in abdomen/pelvis. fibroid uterus. multiple liver cysts. ______________________________________________________________________________ final report indication: fall down ten stairs with abdominal tenderness. evaluate for traumatic intraabdominal injury. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases through the pubic symphysis with 100 cc of optiray contrast. there were no adverse reactions to contrast administration. findings: no prior studies are available for comparison. ct abdomen with iv contrast: atelectasis/scarring is present in both lung bases. there is no pneumothorax. no pleural or pericardial effusions are seen. the liver and spleen are intact without evidence of laceration. no intraabdominal fluid or hematoma is present. there is no free air. multiple focal areas of decreased attenuation are seen in the liver, which likely represent simple cysts. the gallbladder, adrenal glands, stomach, and intraabdominal loops of small and large bowel are unremarkable. there is a possible small cyst in the midportion of the right kidney. the kidneys enhance symmetrically without evidence of injury or obstruction. there is some mild mesenteric stranding, but no frank fluid collection or mesenteric hematoma is seen. ct of the pelvis with iv contrast: the uterus is enlarged, with multiple fibroids. there is a large amount of stool within the rectosigmoid colon. there is no free fluid in the pelvis. distal ureters are unremarkable. the bladder contains a foley catheter and a small amount of internal air. there is no free fluid in the pelvis or pathological inuginal or pelvic lymphadenopathy. osseous structures: no acute fractures are seen. the visualized ribs are free from fractures. impression: no evidence of acute traumatic intraabdominal injury. fibroid uterus. multiple hepatic cysts. (over) [**2188-2-1**] 11:09 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 96828**] ct 100cc non ionic contrast reason: patient s/p fall down 10 stairs with abd tenderness, r/o tra field of view: 36 contrast: optiray amt: 100 ______________________________________________________________________________ final report (cont)",0
493,"[**2132-1-8**] 10:33 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 80447**] ct 150cc nonionic contrast; ct reconstruction reason: ? intraabd etiology for rlq pain. ? h/o porphyria--any contr field of view: 33 contrast: optiray amt: 100 ______________________________________________________________________________ [**hospital 2**] medical condition: 46 year old woman s/p appy with rlq pain x 1 wk reason for this examination: ? intraabd etiology for rlq pain. ? h/o porphyria--any contraindications to contrast? no contraindications for iv contrast ______________________________________________________________________________ wet read: eez tue [**2132-1-8**] 11:20 pm no bowel wall thickening. possible acute right sided fibroid degeneration by ct scan. no fluid in pelvis. small 9mm focus of decreased attenuation in liver, not fully characterized, may represent a hemangioma ______________________________________________________________________________ final report *abnormal! indication: appendectomy ten years ago, now with one week of right lower quadrant pain. technique: axial images of the abdomen and pelvis were acquired helically from the lung bases through the pubic symphysis with oral and 100 cc of optiray contrast. there were no adverse reactions to contrast administration. coronal reformats were made. findings: comparison is made to the earlier pelvic ultrasound from the same day. ct of the abdomen with iv contrast: the lung bases are clear. there are no pleural or pericardial effusions. within the right posterior lobe of the liver (segment 6) is a small focus of decreased attenuation which measures 9 mm in greatest dimension, and is not fully evaluated with this study. this may represent a hemangioma. the spleen, pancreas, adrenal glands, gallbladder, stomach, and intra-abdominal loops of small and large bowel are unremarkable. there is no ascites or pathological mesenteric or retroperitoneal lymphadenopathy. the superior mesenteric vein is patent but not fully opacified, likely due to timing. ct of the pelvis with iv contrast: there is a fibroid uterus. the right- sided fundal fibroid seen on the prior ultrasound has a central area of decreased attenuation. this is suspicious, on ct, for acute fibroid degeneration. the ultrasound appearance was less characteristic. there is no free fluid in the pelvis. the distal ureters and bladder, sigmoid colon, and rectum are unremarkable. the patient is status post appendectomy. no suspicious lytic or sclerotic osseous lesions are identified. ct reconstructions: coronal reformatations show that the patient's large right-sided fibroid demonstrates a low attenuation center. impression: (over) [**2132-1-8**] 10:33 pm ct abdomen w/contrast; ct pelvis w/contrast clip # [**clip number (radiology) 80447**] ct 150cc nonionic contrast; ct reconstruction reason: ? intraabd etiology for rlq pain. ? h/o porphyria--any contr field of view: 33 contrast: optiray amt: 100 ______________________________________________________________________________ final report *abnormal! (cont) 1) right sided fibroid with low attenuation center. this appearance on ct scan is suggestive of acute fibroid degeneration. the ultrasound appearance is less characteristic. there is no free fluid in the pelvis or significant acute intra-abdominal abnormality. 2. small focal area of decreased attenuation in the right posterior lobe of the liver, may represent a hemangioma.",0
494,"[**2113-1-16**] 2:13 am cta chest w&w/o c &recons; cta abd w&w/o c & recons clip # [**clip number (radiology) 19965**] ct 150cc nonionic contrast; cta pelvis w&w/o c & recons reason: r/o dissection contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 4**] medical condition: 75 year old man with upper back pain reason for this examination: r/o dissection no contraindications for iv contrast ______________________________________________________________________________ wet read: eez mon [**2113-1-16**] 2:48 am no dissection. large right, moderate left effusions. multiple ?healing left posterior rib fractures. ______________________________________________________________________________ final report indication: upper back pain. technique: axial images of the chest and abdomen were acquired helically from the lung apices through the aortic bifurcation, before and after administration of 150 cc of optiray contrast. nonionic contrast was used secondary to the patient's cardiac history. there were no adverse reactions to contrast administration. multiplanar reformations were made. comparison: made of the chest ct from [**2111-8-4**]. findings: ct of the chest with iv contrast: changes from prior aortic and mitral valve replacements are present. dual chamber pacemaker leads are present with a control unit overlying the left anterior chest wall. the ascending aorta and aortic arch are mildly calcified. there is no evidence of aortic dissection, periaortic hematoma, or extravasation. there is a large right sided pleural effusion, and a moderate left sided pleural effusion. there is extensive fatty infiltration of the posterior pleural surfaces. no focal consolidations are present within the lung parenchyma. the bronchi are patent to the subsegmental levels. no pathologically enlarged axillary, hilar, or mediastinal nodes are seen. no large central or pulmonary emboli are seen. extensive degenerative changes are seen in the spine. there are multiple likely healing left sided posterior upper thoracic rib fractures. again seen is a large, calcified right inferior thyroid goiter extending substernally. the appearance is not significantly changed. ct of the abdomen with iv contrast: limited evaluation of the upper abdomen shows no focal hepatic lesions. the spleen, pancreas, gallbladder, and bowel are unremarkable. the kidneys enhance symmetrically. there is a left lower pole renal cyst which measures 2.5 cm in greatest dimension. the abdominal aorta is heavily calcified with some mural plaquing. there is no evidence of dissection, aneurysmal dilatation, periaortic hematoma, or dissection. the ostia of the superior mesenteric artery, celiac access, and inferior mesenteric artery are all patent. impression: 1. no aortic dissection. (over) [**2113-1-16**] 2:13 am cta chest w&w/o c &recons; cta abd w&w/o c & recons clip # [**clip number (radiology) 19965**] ct 150cc nonionic contrast; cta pelvis w&w/o c & recons reason: r/o dissection contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) 2. large right and small to moderate left pleural effusion. extensive fatty infiltration of the parietal pleura. 3. stable appearance of the thyroid gland",0
495,"[**2147-1-8**] 11:47 am cta chest w&w/o c &recons; ct 150cc nonionic contrast clip # [**clip number (radiology) 86623**] reason: hypoxia,lung opacities,density around aortic knob on chest xray, evaluate aorta, ? pulmonary embolism admitting diagnosis: rt foot osteomyelitis-dm-hyponatremia field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 3**] medical condition: 66 year old man with hypoxia and bl multifocal opacities reason for this examination: please also do cta to r/o pe in this patient. thank you. no contraindications for iv contrast ______________________________________________________________________________ final report indications: hypoxia and multifocal bilateral parenchymal opacities. evaluate for pulmonary embolism. also, please evaluate for aortic dissection. technique: axial images of the chest, abdomen and pelvis were acquired helically from the lung apices through the aortic bifurcation, with 150 cc of optiray contrast. non-ionic contrast was used secondary to the rapid bolus injection rate required for ct angiography of the pulmonary vasculature and aorta. there were no adverse reactions to contrast administration. multiplanar reformations were made. findings: ct of the chest with iv contrast: the pulmonary vasculature is well opacified and demonstrates no intraluminal filling defects suggestive of pulmonary emboli. there are extensive ground glass opacities with honeycombing in both lung apices. the ground glass opacities extend into the middle lobe on the right, and into the lingula on the left. some lower lobe ground glass opacities are also present. there are multiple enlarged mediastinal and hilar lymph nodes. this may simply reflect volume overload or could be reactive to the pulmonary parenchymal process. there are large bilateral pleural effusions. no pericardial effusions are seen. the ascending and descending thoracic aorta are of normal course and caliber. there is no paraaortic hematoma. there is no evidence of dissection. note is made of bilateral lower pole thyroid cysts. this is located in a substernal position, and may reflect an enlarged thyroid gland. ct of the abdomen with iv contrast: the descending aorta is of normal course and caliber without evidence of dissection. the aortic wall is thickened with extensive mural calcification. the celiac and superior mesenteric arteries, along with the inferior mesenteric artery, are all patent. there is no free intraabdominal air or evidence of obstruction. no focal hepatic or splenic lesions are present. the pancreas is atrophic with multiple calcifications. the kidneys enhance symmetrically without evidence of obstruction or focal mass. the adrenal glands and gallbladder are unremarkable. ct reconstructions: multiplanar reformations show no evidence of pulmonary embolism or aortic dissection. (over) [**2147-1-8**] 11:47 am cta chest w&w/o c &recons; ct 150cc nonionic contrast clip # [**clip number (radiology) 86623**] reason: hypoxia,lung opacities,density around aortic knob on chest xray, evaluate aorta, ? pulmonary embolism admitting diagnosis: rt foot osteomyelitis-dm-hyponatremia field of view: 36 contrast: optiray amt: 150 ______________________________________________________________________________ final report (cont) impression: 1) no evidence of pulmonary embolism or aortic dissection. 2) large bilateral pleural effusions with extensive ground glass opacities throughout all lung lobes, worse in the upper lung zones. there is apparent honeycombing in the apices. ground glass opacities have worsened compared to the prior study.",0
496,"[**2112-3-2**] 4:52 pm cta chest w&w/o c &recons; cta abd w&w/o c & recons clip # [**clip number (radiology) 82013**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: back pain, abd pain field of view: 36 contrast: optiray amt: ______________________________________________________________________________ [**hospital 2**] medical condition: 85 year old woman with reason for this examination: back pain, abd pain, rule out aortic pathology no contraindications for iv contrast ______________________________________________________________________________ wet read: eez wed [**2112-3-2**] 5:49 pm no aortic dissection. findings consistent with mechanical small bowel obstruction. ______________________________________________________________________________ final report *abnormal! indication: back pain and abdominal pain. evaluate for aortic dissection. technique: axial images of the chest abdomen and pelvis were acquired helically from the lung apices through the pubic symphysis before and after administration of 150 cc of optiray contrast. non-ionic contrast was used secondary to the rapid bolus injection rate required for ct angiography of the aorta. there were no adverse reactions to contrast administration. multiplanar reformations were made. findings: ct of the chest with iv contrast: the ascending aorta and descending aorta are normal in course and caliber. there are two small areas of likely asymmetric mural plaque in the aortic isthmus. there is no extravasation, peri- aortic hematoma, dissection, or evidence of active extravasation. no pathologically enlarged axillary, hilar, or mediastinal lymph nodes are seen. atelectasis/scarring is seen in both lung bases. there is mild esophageal dilatation with an air fluid level. there is a large hiatal hernia, which is slightly larger than on the prior study. ct of the abdomen with iv contrast: the descending aorta is of normal course and caliber. there are areas of mural plaquing and aortic calcification. some of the plaque is eccentric, but there is no evidence of aortic dissection. the origins of the celiac axis, superior mesenteric artery, renal arteries, and inferior mesenteric artery are all patent. there is small bowel dilatation proximally extending from the stomach through the proximal jejunum. there is an abrupt transition point in the mid-jejunum, distal to which the small bowel loops are collapsed. there is a small amount of stool seen in the cecum, but the colon is predominantly collapsed. no focal liver lesions are identified, but evaluation is somewhat limited with only one phase of contrast. the gallbladder is mildly distended and contains a stone in the fundus, but there is no evidence of acute cholecystitis. the spleen is unremarkable. the adrenal glands are normal. the pancreas is atrophic. the kidneys enhance symmetrically without evidence of obstruction. likely bilateral renal cysts are present. there is no ascites or pathological (over) [**2112-3-2**] 4:52 pm cta chest w&w/o c &recons; cta abd w&w/o c & recons clip # [**clip number (radiology) 82013**] ct pelvis w/contrast; ct 150cc nonionic contrast reason: back pain, abd pain field of view: 36 contrast: optiray amt: ______________________________________________________________________________ final report *abnormal! (cont) mesenteric or retroperitoneal lymphadenopathy. ct of the pelvis with iv contrast: distal ureters, bladder, and female reproductive structures are unremarkable. there are numerous colonic diverticula, but no evidence of acute diverticulitis. there is no free fluid in the pelvis or pathological inguinal or pelvic lymphadenopathy. degenerative changes are seen throughout the spine. no suspicious lytic or sclerotic lesions are present. ct reconstructions: multiplanar reformatations demonstrate a mechanical small bowel obstruction and a normal aorta. impression: no evidence of aortic dissection. findings consistent with mechanical small bowel obstruction, likely adhesion related. transition point seen in the left mid- abdomen.",0
497,"[**2136-2-12**] 3:52 am cta chest w&w/o c &recons; -59 distinct procedural service clip # [**clip number (radiology) 8020**] ct abdomen w/contrast; ct pelvis w/contrast ct 150cc nonionic contrast reason: r/o injury. please also reconstruct thoracic and lumbar spi contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 2**] medical condition: 48 year old man with c2 fx, mvc seatbelt sign on chest reason for this examination: r/o injury. please also reconstruct thoracic and lumbar spines no contraindications for iv contrast ______________________________________________________________________________ wet read: eez sun [**2136-2-12**] 5:00 am aorta ok. bibasilar atelectasis vs evolving consolidations. no pneumothorax. liver/spleen/panc/adrenals/kidneys ok. no fluid in belly. mesentery ok. left first rib fracture. ______________________________________________________________________________ final report *abnormal! indications: mvc, seatbelt sign on, known c2 fracture. technique: axial images of the chest, abdomen and pelvis were acquired helically from the lung apices through the pubic symphysis with 150 cc of optiray contrast. non-ionic contrast was used secondary to patient debility. there were no adverse reactions to contrast administration. findings: the ascending and descending aorta are intact. there is no evidence of dissection, contour irregularity, active extravasation, or periaortic hematoma. there is a fracture of the left first rib. there are no pleural or pericardial effusions. there is no pneumothorax. there are areas of increased opacity in both lung bases which represent atelectasis or evolving contusions. a patchy opacity is also seen in the lingula. no pathologically enlarged axillary, hilar, or mediastinal lymph nodes are seen. no pneumomediastinum. ct of the abdomen with iv contrast: the liver is intact without adjacent hematoma. the spleen is also intact. the pancreas, adrenal glands, gallbladder, stomach, and intraabdominal loops of small and large bowel are unremarkable. the kidneys enhance symmetrically without evidence of laceration. there is a likely septated cyst in the upper pole of the right kidney and a likely smaller cyst in the lower pole of the left kidney. there is no stranding in the mesentery. there is no ascites or pathological mesenteric or retroperitoneal lymphadenopathy. ct of the pelvis with iv contrast: the bladder contains a foley catheter and some internal air. there is no free fluid in the pelvis. sigmoid colon and rectum are normal. there is no pathological inguinal or pelvic lymphadenopathy. evaluation of portions of the spine are limited by motion artifact. no definite acute fractures are seen in the pelvis or spine. questionable l5 pedicle fractures are seen. (over) [**2136-2-12**] 3:52 am cta chest w&w/o c &recons; -59 distinct procedural service clip # [**clip number (radiology) 8020**] ct abdomen w/contrast; ct pelvis w/contrast ct 150cc nonionic contrast reason: r/o injury. please also reconstruct thoracic and lumbar spi contrast: optiray amt: 150 ______________________________________________________________________________ final report *abnormal! (cont) ct reconstructions: sagittal reconstructions show no evidence of aortic injury. impression: non-displaced fracture of the left first rib and likely bilateral evolving pulmonary contusions vs. atelectasis. no evidence of acute traumatic intraabdominal injury.",0
498,"[**2122-3-16**] 7:21 am cta chest w&w/o c &recons; ct 100cc non ionic contrast clip # [**clip number (radiology) 5883**] reason: eval for pe contrast: optiray amt: 100 ______________________________________________________________________________ [**hospital 2**] medical condition: 52 year old man with high speed mvc, b/l leg fx, leg swelling, fever, eval for pe reason for this examination: eval for pe no contraindications for iv contrast ______________________________________________________________________________ wet read: eez mon [**2122-3-16**] 8:07 am huge central pulmonary emboli, likely bilaterally. wet read version #1 eez mon [**2122-3-16**] 8:07 am huge central pulmonary emboli. ______________________________________________________________________________ final report *abnormal! indication: high speed mvc with bilateral leg fractures, swelling, and fever. evaluate for pulmonary embolus. technique: axial images of the chest were acquired helically from the lung bases to the lung apices before and after administration of 100 cc of optiray contrast. nonionic contrast was used secondary to patient's stability. there were no adverse reactions to contrast administration. multiplanar reformatations were made. findings: comparison is made to the prior study from [**2122-2-27**]. ct of the chest with iv contrast: the pulmonary vasculature is well opacified and demonstrates multiple large pulmonary emboli. the largest is a right main pulmonary artery embolus which extends into the interlobar pulmonary artery and the right upper lobe pulmonary artery. an additional smaller embolus is present at the bifurcation of the medial basal and posterior basal segments. an additional likely embolus is seen to the anterior segment of left upper lobe. there is discoid atelectasis in the left lower lobe. minor dependent changes are seen in the right lower lobe. no pathologically enlarged axillary, hilar, or mediastinal lymph nodes. there are no pleural or pericardial effusions. the visualized portions of the upper abdominal structures are unremarkable. no suspicious lytic or sclerotic osseous lesions are identified. ct reconstructions: multiplanar reformations show multiple large central pulmonary emboli. impression: multiple large central pulmonary emboli. results were discussed with dr. [**first name4 (namepattern1) 5884**] [**last name (namepattern1) **], the emergency department physician, [**name10 (nameis) **] the 8:20am on [**2122-3-16**]. (over) [**2122-3-16**] 7:21 am cta chest w&w/o c &recons; ct 100cc non ionic contrast clip # [**clip number (radiology) 5883**] reason: eval for pe contrast: optiray amt: 100 ______________________________________________________________________________ final report *abnormal! (cont)",0
499,"[**2201-1-18**] 12:17 am cta head w&w/o c & recons; ct 150cc nonionic contrast clip # [**clip number (radiology) 8210**] reason: need cta for assessment of known subarachnoid bleed contrast: optiray amt: 150 ______________________________________________________________________________ [**hospital 2**] medical condition: 78 year old woman with reason for this examination: need cta for assessment of known subarachnoid bleed no contraindications for iv contrast ______________________________________________________________________________ wet read: eez sun [**2201-1-18**] 3:53 am likely 4mm anterior communicating artery aneurysm. large amount of subarachnoid blood. ______________________________________________________________________________ final report *abnormal! indication: subarachnoid hemorrhage. evaluate for aneurysm. technique: axial images of the brain were acquired before and after the administration of 150 cc of optiray contrast, used secondary to the rapid bolus injection rate required for ct angiography of the circle of [**location (un) **]. there were no adverse reactions to contrast administration. multiplanar reformations were made. ct head w&w/0 contrast: on the non-contrast portion of this ct scan, there is a large amount of subarachnoid blood, most of which is located within the region of the basal cisterns and extending anteriorly and laterally to the left along the cerebral convexity. [**doctor last name **]/white matter differentiation remains preserved. there is increased attenuation in the region of the left internal carotid just before the origin of the middle cerebral artery. on the cta portion of the exam, there is a likely aneurysm arising from the region of the anterior communicating artery. no acute extravasation is seen. the visualized portions of the internal carotid arteries, proximal middle cerebral arteries, posterior communicating arteries, posterior inferior cerebellar arteries bilaterally, and posterior cerebral arteries are all within normal limits. impression: large amount of subarachnoid blood with likely aneurysm arising from the anterior communicating artery.",0